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LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 

PRESENTED  BY 

DONALD  SEEKS 


Published  by  Licence  of  the  Board  of   Trade  under  the  "  Trading 

with  the  Enemy  Amendment  Act,   1916." 

DEMENTIA  PRECOX 

AND 

PARAPHRENIA 

BY 

Professor  EMIL  KRAEPELIN  of  Munich 


TRANSLATED   BY 

R.   MARY   BARCLAY,   M.A.,   M.B. 

From  the  Eighth  German  Edition  of  the  "  Text-Book  of  Psychiatry,' 
vol.  iii.,  part  ii.,  section  on  the  Endogenous  Dementias 

EDITED   BY 

GEORGE    M.   ROBERTSON,   M.D.,   F.R.C.P.  (Edin.) 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh 
and  Physician  to  the  Royal  Asylum,  Momingside 


CHICAGO  MEDICAL  BOOK  GO. 

COR.  CONGRBSS  &  HONORE  STS. 

Chicago 


_^    /^ 


EDITOR'S   PREFACE. 

Dementia  Precox  has  excited  more  interest  and 
speculation  than  any  other  form  of  insanity  in  our  time, 
with  the  possible  exception  of  general  paralysis  of  the 
insane.  I  therefore  value  highly  the  usefulness  of  the  work 
that  Dr  Mary  Barclay  has  done  in  thus  bringing  before 
English-speaking  physicians  a  faithful  translation  of  the  views 
of  Professor  Kraepelin,  who  is  the  recognised  authority  on 
this  subject.  In  no  country  has  there  been  less  inclination 
to  accept  his  doctrines  without  qualification  than  in  this,  but 
so  important  are  they,  that  every  physician  of  the  mind,  who 
would  keep  himself  abreast  of  modern  clinical  research,  must 
be  familiar  with  them.  The  present  work  therefore  supplies 
a  want  in  giving  in  an  accessible  form  the  complete  and  latest 
account  of  this  subject  by  Professor  Kraepelin.  In  addition, 
there  is  no  other  publication  in  the  English  language  which 
deals  solely  with  dementia  praecox  in  all  its  various  aspects. 

Professor  Kraepelin  informs  us  that  he  got  the  starting 
point  which  led  to  dementia  praecox  being  regarded  by  him 
as  a  distinct  disease,  in  the  year  1896.  He  admits  "that 
Clouston  also,  who  spoke  of  an  '  adolescent  insanity,'  had 
evidently  before  everything  dementia  praecox  in  view,  though 
he  did  not  yet  separate  it  from  manic-depressive  cases, 
which  likewise  often  begin  about  this  time."  The  identity  of 
Clouston's  "secondary  dementia  of  adolescence"  with  the 
chief  forms  of  dementia  praecox  is  quite  apparent  to  anyone 
reading  the  remarkable  address  on  dementia  which  he 
delivered  in  1888  when  President  of  the  Medico-Ps^^chological 
Association.  While,  however.  Sir  Thomas  Clouston  regarded 
some  of  his  cases  of  adolescent  insanity  as  being  of  an  un- 
favourable type  which  often  ended  in  secondary  dementia. 
Professor  Kraepelin  would  regard  these  very  cases,  from  their 
initial  symptoms  onward,  as  being  examples  of  a  distinct 
form  of  disease,  namely  dementia  praecox.  This  situation 
therefore  recalls  in  an  interesting  manner  the  circumstances 
connected  with  the  discovery  of  general  paralysis  of  the 
insane.  Esquirol  and  his  pupils  had  for  seventeen  years  been 
observing  cases  of  "insanity  complicated  with  paralysis," 
when  Bayle,  in  1822,  boldly  asserted  that  the  symptoms  of 
this  clinical  condition  were  those  of  a  separate  and  definite 
disease.  This  hypothesis  has  proved  true  ;  is  it  too  soon  yet 
to  say  the  same  of  the  former  ? 


ii  EDITOR'S   PREFACE 

Professor  Kraepelin's  task  in  depicting  the  characteristic 
features  of  dementia  pr.tcox  has  not  been  an  easy  one,  and 
even  now  he  has  not  reached  finality  in  his  opinions.  He  is 
not  satisfied  with  his  delimitation  of  its  boundaries,  nor  with 
all  the  sub-divisions  which  he  has  created,  though  he  believes 
that  his  main  thesis  has  been  substantiated.  Neither  terminal 
dementia  nor  precocity  is,  however,  an  essential  element  of 
the  clinical  picture,  though  his  reluctance  to  discard  the 
former  is  very  evident,  and  this  masterly  summary  has  been 
as  a  matter  of  fact  prepared  solely  from  observation  of  cases 
which  actually  became  demented. 

Now  that  general  paralysis  of  the  insane,  after  a  century 
of  observation  and  research,  has  yielded  up  most  of  its 
secrets,  by  far  the  most  important  practical  problem  facing 
the  psychiatrist  and  the  community,  in  the  domain  of  mental 
hygiene,  is  that  of  dementia  praecox.  The  patients  suffering 
from  this  disease  form  the  major  part  of  the  inmates  of  our 
mental  hospitals.  The  heavy  financial  burden  imposed  upon 
the  public  for  the  treatment  of  the  insane,  resolves  itself 
therefore  very  largely  into  the  outlays  needed  for  the  lifelong 
care  of  the  almost  hopeless  victims  of  this  disorder.  More- 
over, as  the  disease  does  not  directly  cause  death,  and  as 
such  patients  lead  protected  lives  and  live  long,  they  tend 
to  accumulate.  They  thus  form  the  chief  reason  for  the 
periodical  necessity  of  enlarging  our  mental  hospitals,  and  of 
erecting  new  ones.  Could  a  study  of  the  causes  and  treatment 
of  this  disorder  result  in  its  prevention  or  diminution,  its  cure 
or  alleviation,  a  practical  benefit  to  society  of  the  most  direct 
and  valuable  kind  would  be  conferred.  Such  an  enquiry 
should  have  the  support  of  the  Ministry  of  Health  as  this 
disease  costs  the  State  more  than  any  other.  How  to  avert  this 
dementia  continues  to  be  the  cardinal  problem  of  psychiatry. 

It  is  hoped  that  the  publication  of  this  translation  will 
stimulate  the  interest  of  English-speaking  physicians  in 
these  peculiar  states  of  mental  enfeeblement,  promote  further 
clinical  observation  and  research,  and  lead  to  greater  accuracy 
of  diagnosis  and  prognosis,  with  a  better  understanding  of 
the  nature  of  the  disease. 

GEORGE  M.  ROBERTSON. 

U.NIVERSITY  OF   EDINBURGH, 
July  1919. 


TRANSLATOR'S    PREFACE. 

As  the  aim  of  this  translation  is  to  bring  the  views  of 
Professor  Kraepelin,  of  Munich,  on  dementia  praecox  before 
the  English-speaking  members  of  the  medical  profession  who 
may  not  be  intimately  acquainted  with  German,  I  have  made 
it  as  literal  as  seemed  consistent  with  readable  English, 
Professor  Kraepelin's  Psychiatry  is  the  leading  German  text- 
book on  disorders  of  the  mind,  and  I  therefore  willingly 
acceded  to  the  wish  of  Dr  George  Robertson  to  make  a 
complete  translation  of  the  section  on  dementia  praecox. 
This  special  disease  still  requires  much  elucidation,  and  in 
its  study  medical  practitioners,  educationalists,  and  crimin- 
ologists may  well  work  together.  It  is  especially  on  the 
educational  side  that  Professor  Kraepelin's  observations  or 
investigations  appear  to  be  deficient.  It  should  not  be 
difficult  in  this  country  to  collect  the  required  facts  relating 
to  individual  cases,  and  to  a  certain  extent  this  is  being 
done  already.  When  these  facts  are  classified,  much  benefit 
should  accrue  to  education,  medical  advancement,  and  the 
public  welfare. 

To  Dr  George  Robertson  I  have  to  express  my  thanks 
for  many  useful  suggestions,  and  to  Dr  Walker  for  the 
unwearying  care  with  which  he  has  revised  the  proofs. 

R.  MARY  BARCLAY. 
Edinburgh,  July  1919. 


CONTENTS. 


Prbface  ....... 

Introduction— THE  ENDOGENOUS  DEMENTIAS 

I.     DEMENTIA  PRECOX 

II.     PSYCHIC  SYMPTOMS 

Perception       ..... 

Attention         ..... 

Hallucinations  (thoughts  heard,  thought  influence) 

Orientation      ..... 

Consciousness ..... 

Memory  .  .     "       . 

Retention  (pseudo-memories)  . 

Train  of  thought  (loss  of  mental  activity) 

Association 

Stereotypy 

Paralogia,  evasion 

Constraint 

Mental  efficiency 

Judgment 

Delusions 

Emotional  dulness,  ataxia  of  the  feelings 

Weakening  of  volitional  impulse 

Automatic  obedience  (catalepsy,  echolalia,  echopraxis) 

Impulsive  actions         .... 

Catatonic  excitement  .... 

Stereotyped  attitudes  and  movements 

Mannerisms     ..... 

Parabulia         ..... 

Negativism  (autism,  stupor)    . 

Personality      ..... 

Practical  efficiency      .... 

Movements  of  expression 

Incoherence     ..... 

Stereotypy  (verbigeration) 

Negativism  (mutism,  evasion) 

Derailments  in  word-finding    . 

Paraphasia       ..... 

Neologisms      ..... 

Akataphasia    ..... 

Syntax  ..... 

Derailments  in  train  of  thought 

III.     GENERAL  PSYCHIC  CLINICAL  PICTURE 
Blunting  of  emotions  .... 
Intrapsychic  ataxia      .... 


CONTENTS 


Chap. 
IV. 


Pace 


BODILY  SYMPTOMS 
Headaches 
Pupillar)'  disorders 
Tendon  reflexes 
Muscular  movements 
Seizures 
Grimacing 
Aphasia 

Vasomotor  disorders 
Blood -pressure 
Respiration 
Secretion  of  saliva 
Temperature    . 
«  Menses 

Blood-picture  . 

Metabolism 

Changes  in  the  thyroid 

Sleep  . 

Nourishment    . 

Weight 

V.    CLINICAL  FORMS 

Dementia  praecox  simplex 

Silly  dementia  prsecox,  hebephi 

Simple  depressive  dementia  praecox,  stupor 

Delusional  depressive  dementia  praecox 

Circular  dementia  pnecox 

Agitated  dementia  prjEcox 

Periodic  dementia  prcecox 

Catatonia,  excitement,  stupor  (melancholia  attonita) 

Paranoid  dementia  praecox,  gravis 

Paranoid  dementia  pnrcox,  mitis 

Confusional  speech  dementia  proecox,  schizophasia 

VI.     COURSE,  REMISSIONS 

VII.     ISSUE     . 

Recovery,  recovery  with  defect 
Simple  weakmindedness 
Hallucinatory  weakmindedness 
Paranoid  weakmindedness 
Drivelling  dementia 
T)ull  dementia 
Silly  dementia 
Manneristic  dementia 
Negativistic  dementia 
Prognostic  indications 
Death,  mortality 

VIII.     MORBID  ANATOMY 
Cell  morbidity 
Changes  in  glia 


CONTENTS 


Vll 


Chap. 


IX. 


XL 


XII. 


XIII. 


Atrophy  of  medullary  fibres     .... 
Relations  of  the  changes  in  the  cortex  to  the  clinical  picture 

FREQUENCY,  CAUSES 
Time  of  life 
Engrafted  hebephrenia 
Idiocy 

Dementia  prsecocissima 
Late  catatonias 
Dementia  tardiva 
Sex 

General  conditions  of  life 
Hereditary  predisposition 
Injury  to  the  germ,  alcoholism,  syphilis 
Personal  idiosyncrasy  . 
External    causes — over-exertion,    infection,    syphilis,    head 

injuries,  alcohol,  imprisonment,  reproduction 
Sexual  life        .  .  .  ,  , 

Auto-intoxication  .... 

Freudian  complexes     .... 

DELIMITATION  .  .  ,  . 

Paranoid 'forms  .... 

Catatonia         .  .  .  .  . 

Late  catatonias  .... 

Periodic  forms  .... 

Confusion  of  speech  .... 

DIAGNOSIS 

Catatonic  symptoms     .... 
Psychopathic  states     .... 
Imbecility  and  idiocy  .... 
Manic-depressive  insanity 
Hysteria  ..... 

Psychogenic  psychoses 

Dissimulation  ..... 
Epilepsy  ..... 

Paralysis  ..... 

Amentia  (confusional  or  delirious  insanity) 
Cerebral  syphilis  .... 

Paranoid  diseases         .... 

HOW  TO  COMBAT  IT  .  .  . 

Treatment  of  the  cause  (castration,  immunization,  excision  o 

the  thyroid),  prophylaxis . 
Treatment  of  the  morbid  phenomena,  occupation 
Treatment  by  leucocytosis 

PARAPHRENIA  .... 

Definition  and  classification     . 
Paraphrenia  systematica 
Paraphrenia  expansiva 
Paraphrenia  confabulans 
Paraphrenia  phantastica 


LIST   OF    ILLUSTRATIONS. 


FIG. 
I. 
2. 
3- 
4- 

5- 
6. 

7- 


lO. 

II. 

12. 
13- 

14. 
15- 

16. 

17. 
18. 

19- 

20. 
21. 
22. 

23- 

24. 

25- 

26. 
27. 
28. 
29. 
30- 

31- 
32. 
33. 
34. 
35- 
36. 
37- 


Calculation  Tests 

Bodilj  Influences 

Group  of  Schizophrenic  Patients 

Waxy  Flexibility  {a) 

Waxy  Flexibility  (6) 

Waxy  Flexibility  {c) 

Hair-pulling  Patient 

Embroidered  Handkerchief  . 

Peculiar  Stocking  (Catatonia) 

Drawings  (Metamorphoses) 

Senseless  Drawing    . 

Queer  Drawing 

Normal  Finger  Movement    . 

Simple  Finger  Movement  in  Catatonia  (a) 

Simple  Finger  Movement  in  Catatonia  (6) 

Simple  Finger  Movement  in  Catatonia  (<r) 

Simple  Finger  Movement  in  Catatonia  (d) 

Normal  Rhythmical  Finger  Movements 

Rhythmical  Finger  Movements  in  Catatonia 

Temperature  Chart  at  the  End  of  Life  of  a  Catatonic  Patient 

Body  Weight  in  Catatonic  Stupor  with  Dementia 

Body  Weight  in  Catatonic  Excitement 

Body  Weight  in  Alternation  of  Stupor  and  Excitement  with  Dementia 

Fluctuations  of  Body  Weight  at  the  Commencement  of  Dementia  Priecox 

Fluctuations  of  Body  Weight  in  Periodic  Excitement 

Stuporous  Patient  Lying  on  the  Edge  of  the  Bed 

Finger  Contracture  in  Catatonia 

Stuporous  Patient 

Expression  of  Face  in  Catatonic  Stupor  (a) 

Expression  of  Face  in  Catatonic  Stupor  {d) 

Nasal  Stopper  of  a  Paranoid  Patient 

Ornamented  Paranoid  Patient 

Hopping  Patient 

Patient  in  Distorted  Attitude 

Patient  Continually  Holding  her  Head 

Nerve  Cells  surrounded  by  Glia  Nuclei  x  484 

Fibrinous  Granules  in  Glia  Cells  x  484 


ILLUSTRATIONS 


FIG. 

39- 

40. 
41. 

42. 
43- 


Normal  Nerve  Cells  with  Glia  Nuclei  x  484 

Sclerotic  Nerve  Cells  in  Dementia  Pra-cox  x  484 

Healthy  Nerve  Cells  X  484    ...... 

Highly    Morbid    Nerve    Cells    filled    with    Lipoid    Products    of 
Disintegration  x  484  ...... 

Percentage   Distribution   of   1054  Cases  of  Dementia   Precox  at 
Different  Ages    ....... 

Idiot  with  Manneristic  Movements  ..... 


I'AUS 

217 
217 
218 

218 

226 
228 


SPECIMENS    OF   WRITING. 


1.  Incoherence  . 

2.  Incoherence  with  Stereotypy 

3.  Stereotypy     . 

4.  Letter  of  a  Hebephrenic 

5.  Writing  of  a  Paranoid  Patient 

6.  Writing  ot  the  Same  Patient  Seven  Months  Later 

7.  Paraphrenia  Phantastica  x  § 


57 
58 
64 
100 
174 
'75 
321 


INTRODUCTION. 
THE   ENDOGENOUS   DEMENTIAS. 

A  series  of  morbid  pictures  are  here  brought  together 
under  the  term  "^endogenous  dementias "  merely  for  the 
purpose  of  preliminary  inqu^rJ^  Their  clinical  relations  are 
not  yet  clear,  but  they  all  display  two  peculiarities,  that  they 
are  in  the  first  place,  so  far  as  can  be  seen,  not  occasioned 
from  without  but  arisefroni  internal  causes,  and  that  secondly, 
at  least  in  the  great  majority  of  cases,  they  lead  to  a  more  or 
less  vvell-niarked  mental  enfeeblement.  It  appears  that  this 
form  of  mental  weakness,  in  spite  of  great  differences  in  detail, 
exhibits  many  features  in  common  with  other  forms  of 
dementia,  such  as  are  known  to  us  as  the  result  of  paralysis, 
senility  or  epilepsy.  For  this  reason  I  have  hitherto  descrTbe3 
under  the  one  name,  dementia  pra;cox.  the  morbid  pictures 
under  consideration.     Bleuler  also  has  taken  them  to^rether 


in  his  "group  of  the  schizophrenias,"  without  trying  to  make 
a  further  division  of  this  group.  I  consider  it  an  open 
question  whether  the  same  morbid   process  is  not  after  all  the 


cause  of  Jj^p  (^u/prgpnf-  fnrmt;  though  differjiip^  in  the  poiiifof 
attack  and  taking  a  varymg-  course.  It  appears  to  me 
expedient  at  the  present  stage  to  separate  out  a  number  of 
these  clinical  pictures  from  the  domain  of  dementia  praecox, 
which  in  any  case  is  very  extensive.  Nevertheless  it  is 
dementia  praecox  w.hich  we  must  take  as  the  first  division  of 
the  endogenous  dementias  to  be  reviewed. 

These  clinical  pictures  referred  to  differ  considerably  in 
one  direction  or  another  from  the  current  conceptions  of 
dementia  praecox.  It  would  perhaps  have  been  possible  to 
carry  this  separation  still  further,  and,  for  instance,  allow  a 

A 


2  INTRODUCTION 

separate  place  also  to  the  forms  which  have  a  periodic  course, 
or  which  lead  to  confusion  of  speech.  Meanwhile  this  has 
not  been  done,  and  therefore,  to  begin  with,  only  those  forms 
have  been  singled  out  and  placed  together  subsequently^ 
which  are  distinguished  in  their  whole  course  by  very  definite 
manifestations  of  peculiar  disturbances  of  intellect  while 
lacking  enfeeblement  of  volition  and  especially  of  feeling,  or 
at  least  such  symptoms  are  only  feebly  indicated.  It  seems 
to  me  that  the  term  "  paraphrenia,"  which  is  now  no  longer 
in  common  use,  is  in  the  meantime  suitable  as  the  name  of 
the  morbid  forms  thus  delimited  which  are  here  by  way  of 
experiment  brought  together. 

'  Chapter  xiii.,  p.  283. 


CHAPTER    I. 

DEMENTIA  PRiECOX. 

Dementia  pnecox^  consists  of  a  series  of  states,  the 
coinjioif^ characteristic  of  whiclT  is  a  peculiar_dgsitru(:!tioti  of 
the  internal _CDi3iiections~~ot  the  psyoTic"  personalityT "  Ihe 
el!ects  of  this  injury  pr^iixyrfnnSXe~^n  the  '^etfTolIorfal  and 
volitional  spheres  of  mental  life.  To  begin  with,  the  assertion 
that  this  is  a  distinct  dT5e^se"has  met  with  repeated  and  decided 
opposition,  which  has  found  its  strongest  expression  in  the 
writings  of  Marandon  de  Montyel  and  of  Serbsky.-  But 
even  though  in  many  details  there  are  profound  differences 
of  opinion,  still  the  conviction  seems  to  be  more  and  more 
gaining  ground  that  dementia  praecox  on  the  whole  represents 
a  well  characterised  form  of  disease,  and  that  we  are  justified 
in  regarding^  the^maJorTfy*'at-v£ast  of  the  clinical  pictures 
which  are  brought  together  here  as  the  expression  of  a  single 
morbid  process,  though  outwardly  they  Slten  diverge  veryfar 
from  one  another. 

"  THe^oBJections  have  been  directed  even  more  against  the 
name  than  against  the  clinical  congeftUon.  I  got  the  starting 
point  of  the  line  of  thought  wlT^h  in  iBg6  led  to  dementia 
praecox  being  regarded  as  a  distinct  disease,  on  the  one  hand 
from  the  overpowering  impression  of  the  states  of  dementia 
quite  similar  to  each  other  which  developed  from  the  most 
varied  initial  clinical  symptoms,  on  the  other  hand  from  the 

'  Finzi  e  Vedrani,  Rivista  sperim.  de  freniatria,  xxv.  1899 ;  Christian,  Ann. 
medico-psychol.  1899,  i,  43  ;  Tromner,  Das  Jugendirresein  (Dementia  piKCox), 
1909;  Serieux,  Gaz.  hebdomad.  Mars  1901  ;  Revue  de  psychiatrie,  Juin  1902; 
Jahrmiirker,  Zur  Frage  der  Dementia  prcecox.  1902;  Meeus,  ,de  la  demence 
precoce  chez  lez  jeunes  gens.  1902 ;  Masselon,  Psychologic  des  Demences 
precoces  ;  de  la  demence  precoce.  1904  ;  Stransky,  Centralblatt  fiir  Nei  venheilkunde 
xxvii.  I  ;  tJber  die  dementia  praecox.  1909  ;  Bernstein,  AUg.  Zeitschr.  f.  Psychiatrie, 
Ix.  554 :  Deny  et  Roy,  la  demence  precoce.  1903  ;  Pighini,  Rivista  sperimentale 
di  freniatria,  xxxiv.  3  ;  Hochp,  Deutsche  Klinik  von  Leyden-Klemperer,  vi.  2, 
197;  HeclU,  American  Journal  of  nervous  and  mental  diseases,  1905,  689; 
Evensen,  Dementia  praecox.  1904 ;  Rizor,  Archiv  f.  Psychiatrie.  xliii.  760  ;  Wieg- 
Wickenthal,  Zur  Klinik  der  Dementia  prjecox.  1908 ;  Bleuler-Jahrmiirker, 
AUgem.  Zeitsclir  f.  Psychiatrie,  Ixv.  429 ;  Bleuler,  Dementia  praecox  oder 
Oruppe  der  Schizophrenien,  Aschaffenburgs  Handbuch  der  Psychiatrie,  191 1 
(Literatur)  Deny  et  Lhermitte,  Traite  international  de  psychologic  pathologique, 
ii.  439,  191 1. 

'^Serbsky,  Annales  medico-psychologiques  1903,  2.  379;  Marandon  dc 
Montyel,  ebenda  1905,  2,  246  ;  Soutzo,  ebenda  1907,  i.  243. 


4  DEMENTIA  PRECOX 

experience  connected  with  the  observations  of  Hecker  that 
these  peculiar  dementias  seemed  to  stand  in  near  relation  to 
the  period  of  youth.  As  there  was  no  clinical  recognition  of 
it,  the  hrst  thing  to  be  done  for  the  preliminary  marking  off 
of  the  newly  circumscribed  territory,  was  to  choose  a  name 
which  would  express  both  these  points  of  view.  The  name 
"dementia  praecox,"  which  had  already  been  used  by  MoreP 
and  later  by  Pick  (i  891),  seemed  to  me  to  answer  this  purpose 
sufficiently,  till  a  profounder  understanding  would  provide  an 
appropriate  name. 

It  has  since  been  found  that  the  assumptions  upon  which 
the  name  chosen  rested  are  at  least  doubtful.  As  will  have 
to  be  explained  more  in  detail  later,  the  possibility  cannot  in 
the  present  state  of  our  knowledge  be  disputed,  that  a 
certain  number  of  cases  of  dementia  praecox  attain  to 
complete  and  permanent  recovery,  and  also  the  relations  to 
the  period  of  youth  do  not  appear  to  be  without  exception. 
I  certainly  consider  that  the  facts  are  not  by  any  means 
sufficiently  cleared  up  yet  in  either  direction.  If  therefore  the 
name  which  is  in  dispute,  even  though  it  has  been  already 
fairly  generally  adopted,  is  to  be  replaced  by  another,  it  is  to 
be  hoped  that  it  will  not  soon  share  the  fate  of  so  many  names 
of  the  kind,  and  of  dementia  praecox  itself  in  giving  a  view  of 
the  nature  of  the  disease  which  will  turn  out  to  be  doubtful 
or  wrong. 

From  this  point  of  view,  as  Wolff  showed,  a  name  that  as 
far  as  possible  said  nothing  would  be  preferable,  as  dysphrenia. 
Ths  name  proposed  by  Evensen  "  amblynoia,"  "  amblythymia," 
further  the  "demenza  primitiva"  of  the  Italians,  or  the  one 
preferred  by  Rieger,  which  meanwhile  has  certainly  been 
already  used  in  a  narrower  sense,  "  dementia  simplex,'* 
might  also  be  taken  into  consideration.  Bernstein  speaks  of 
a  "  paratonia  progressiva,"  a  name  that  would  suit  only  a  part 
of  the  observed  cases.  Other  investigators  accentuate  the 
peculiar  disturbance  of  the  inner  psychic  association  in  our 
patients  and  call  the  disease  "  dementia  dissociativa," 
"  dissecans,"  "  sejunctiva  "  or  with  Bleuler  "  schizophrenia." 
It  remains  to  be  seen  how  far  one  or  other  of  these  names 
will  be  adopted. 

'  Morel,  Traite  des  maladies  mentales,  566,  i860. 


CHAPTER     II. 
PSYCHIC  SYMPTOMS 

The  complexity  of  the  conditions  which  we  observe  in 
the  domain  of  dementia  prsecox  is  very  great,  so  that  their 
inner  connection  is  at  first  recognizable  only  by  their 
occurring  one  after  the  other  in  the  course  of  the  same 
disease.  In  any  case  certain  fundamental  disturbances, 
even  though  they  cannot  for  the  most  part  be  regarded  as 
characteristic,  yet  return  frequently  in  the  same  form,  but  in 
the  most  diverse  combinations,  We  shall  therefore  try  to 
give  a  survey  of  the  general  behaviour  of  the  psychic  and 
physical  activities  before  we  describe  the  individual  clinical 
manifestations  of  the  disease.^ 

Perception  of  external  impressions  in  dementia  praecox 
is  noTnJsually  lessened  to  any  great  extent  as  far  as  a 
superficial  examination  goes.  The  |3atients  perceive  in 
general  what  ^oes  on  around  them  often  much  better  than 
6nfe  woUld"'expect_Jrom  IhfitrbeKSvio'uF.  One  is  sometimes 
surprised  tHafpatlents  to^"arr  appearance  wholly  dull,  have 
perceived  correctly  all  possible  details  in  their  surroundings, 
kiTowThe  names  of  their  fellow  patients,  and  notice  changes 
in  the  dress  of  the  physician.  By  more  accurate  observations, 
however,  such  as  were  carried  out  by  Busch  and  by  Gregor,  it 
becomes  evident  that  the  extent  and  especially  the  trust- 
worthiness of  perception  are  decidedly  decreased.  This  is 
chiefly  so  in  the  acute  phases  of  the  malady,  and  then  again 
in  the  last  periods  of  its  course.  It  was  specially  striking 
in  the  experiments  of  Busch  to  find  that  the  patients  usually 
made,  along  wi^h  a  few  correct  statements,  a  great  many 
j^hoUy  false  ones.  i:*or  instance,  in  the  perception  of  letters 
"rtrey  uttered  repeatedly  the  same  arbitrary  series  or  some- 
times parts  of  the  alphabet.  It  was  evident  that  they  could 
not  make  the  effort  to  retain  and  to  reproduce  what  they 
really  saw  ;  instead  of  this  they  named  at  random  whatever 
happened  to  occur  to  them. 

Attention. — This  behaviour  is  without  doubt  nearly  re- 
lated to  the  disorder  of  attention  which  we  very  frequently  find 

^  Albrecht,  Allgem.  Zeitschr.  f.  Psychiatric  Ixvii.  659. 


6  DEMENTIA  PRECOX 

conspicuously  developed  in  our  patients.  It  is  quite  common 
for  them  to  lose  both  inclination  and  ability  on  their 
own  initiative  to  keep  their  attention  fixed  for  any  length 
of  time.  It  is  often  difficult  enough  to  make  them  attend 
at  all.  The  patients  do  not  look  up  when  spoken  to,  and 
betray  riei t'HeF~byTbbk  nor  by  demeanour  in  any  way  that 
they  are  sensitive  to  external  impressions.  )|Although  this  is 
so,  they  have 'perhaps  perceived  all  the  details,  but  have 
not  experienced  an)-  real  internal  appreciation  of  their 
significance.  \  Sometimes  in  cases  of  profound  stupor  or  in 
many  other  insane  states  it  is  no  longer  possible,  even  by 
the  strongest  stimulus,  to  force  the  patients  to  show  any 
interest. 

But  the  patients  do  not  take  any  notice  of  what  they 
may  perceive  quite  well,  nor  do  they  try  to  understand  it  ; 
they  do  not  follow  what  happens  in  their  surroundings  ev'en 
though  it  may  happen  to  be  of  great  importance  for  them. 
They  do  not  pay  attention  to  what  is  said  to  them,  they  do 
not  trouble  themselves  about  the  meaning  of  what  they  read. 
On  this  depends  what  was  ob.served  by  Ossipow  in  some  of 
the  patients,  "photographic"  reading,  the  thoughtless  repetition 
of  what  is  printed  with  all  the  signs  of  punctuation. 
Further  there  is  seen  the  tendency  of  groups  of  patients, 
when  they  transcribe  to  copy  carefully  all  mistakes,  correc- 
tions, interpolations,  and  marginal  notes.  In  psychological 
experiments  the  patients  cannot  stick  to  the  appointed 
exercise  ;  they  feel  no  need  to  collect  their  thoughts  in  the 
appointed  manner,  or  to  reach  a  satisfactory  solution. 
Perhaps  the  experience  related  by  Dodge  and  DiefendorfT, 
that  patients  do  not  usually  follow  a  moving  pendulum 
continuously,  as  normal  persons  do,  but  intermittently  and 
hesitatingly,  may  be  explained  by  a  similar  disorder  of 
attention. 

With  this  loss  of  capacity  to  follow  a  lead  is  connected 
a  certain  unsteadiness  of  attention  ;  the  patients  digress,  do 
not  stick  to  the  point,  let  their  thoughts  wander  without 
voluntary  control  in  the  most  varied  directions.  On  the 
other  hand  the  attention  is  often  rigidly  fixed  for  a  long  time, 
so  that  the  patients  stare  at  the  same  point,  or  the  same 
object,  continue  the  same  line  of  thought,  or  do  not  let 
themselves  be  interrupted  in  some  definite  piece  of  work. 
Further  it  happens  that  they  deliberately  turn  away  their 
attention  from  those  things  to  which  it  is  desired  to  attract 
it,  turn  their  backs  when  spoken  to,  and  turn  away  their 
eyes  if  anything  is  shown  to  them.  But  in  the  end  there  is 
occasionally    noticed   a    kind   of  irresistible  attraction  oj  the 


PSYCHIC  SYMPTOMS  7 

attention  to  casual  external  impressions.  The  patients 
involuntarily  introduce  into  their  speech  words  that  they 
have  heard,  react  to  each  movement  of  their  neighbours,  or 
imitate  them.  Leupoldt  describes  patients  who  instinctively 
had  to  touch  or  count  objects  as  they  came  within  their  field 
of  vision.  On  the  disappearance  of  stuporous  conditions  a 
distinct  inquisitiveness  sometimes  appears  in  the  patients  : 
they  surreptitiously  watch  what  happens  in  the  room,  follow 
the  physician  at  a  distance,  look  in  at  all  open  doors,  but 
turn  away  if  any  one  calls  them.  We  shall  later  see  that 
all  these  disorders  of  that  inner  activity  of  volition,  which 
we  call  attention,  represent  only  partial  manifestations  of 
general  morbid  changes  in  the  processes  of  volition. 

Hallucinations. — Sensation  is  very  often  profundly  dis- 
ordered in  our  patients  as  is  evident  by  the  occurrence  of 
hallucinations.  They  are  almost  never  wanting  in  the  acute 
and  subacute  forms  of  the  disease.  Often  enough  they 
accompany  the  whole  course  of  the  disease ;  but  more 
frequently  they  gradually  disappear,  to  reappear  more  dis- 
tinctly from  time  to  time  in  the  last  stages.  By  far  the  most 
frequent  are  halluci?iations  of  hearing.  At  the  beginning 
these  are  usually  simple  noises,  rustling,  buzzing,  ringing  in 
the  ears,  tolling  of  bells  ("  death-knell  "),  k^iocking,  moving 
of  tables,  cracking  of  whips,  trumpets,  yodel,  singing,  weeping 
of  children,  whistling,  blowing,  chirping,  "shooting  and  death- 
rattle  "  ;  the  bed  echoes  with  shots  ;  the  '_'  Wild  Hunt  "  makes 
.an  uproar  ;  Satan  roars  under  the  bed. 

And  then  there  develops  gradually  or  suddenly  the 
symptom  peculiarly  characteristic  of  dementia  praecox, 
namely,  the  hearing  of  voices.  Sometimes  it  is  only  whisper- 
ing, "  as  if  it  concerned  me,"  as  a  patient  says,  a  secret 
language,  "taunting  the  captive";  sometimes  the  voices  are 
loud  or  suppressed,  as  from  a  ventriloquist,  or  the  call  of  a 
telephone,  "  children's  voices " ;  a  patient  heard  "  gnats 
speak."  Sometimes  they  shout  as  in  a  chorus  or  all  con- 
fusedly ;  a  patient  spoke  of  "drumming  in  the  ear";  another 
heard, ."  729,000  girls."  Sometimes  the  voices  appear  to  have 
a  metallic  sound,  they  are  "  resonant  voices,"  "  organ  voices," 
or  as  of  a  tuning-fork.  At  other  times  they  do  not  appear 
to  the  patients  as  sense  perceptions  at  all  ;  they  are  "  voices 
of  conscience,"  "  voices  which  do  not  speak  with  words," 
voices  of  dead  people,  "  false  voices,"  "  abortive  voices."  A 
patient  said  :  "  It  appeared  to  me  in  spirit,  as  though  they 
would  find  fault,  without  having  heard  it."  There  is  an 
"  inner  feeling  in  the  soul,"  an  "  inward  voice  in  the 
thoughts  ";  "  it  is  thought  inwardly  in   me  ";  it  "  sounded  as 


8  DEMENTIA  PR^XOX 

if  thought ";  "  it  was  between  hearing  and  foreboding " — 
in  such  ways  the  patients  express  themselves  about  these 
sensory  disturbances. 

The  illusions  not  infrequently  are  connected  with  real 
noises.  The  clock  speaks  as  if  it  wore  enchanted  ;  the 
rushing  of  water  is  changed  into  words ;  each  step  under 
the  patient  speaks  ;  a  patient  "  heard  the  thoughts  of  others 
out  of  the  soles  of  his  boots."  Here  and  there  the  voices 
have  a  rhythmical  cadence,  probably  in  connection  with  the 
carotid  pulse. 

The  voices  are  often  referred  to  the  ear  or  the  head ;  they 
are  "voices  m  the  ear";  there  are  evil  spirits  in  the  ear,  a 
telephone,  a  receiver,  a  phonograph  in  the  head  ;  "  the  brain 
talks."  One  ear  may  be  exclusively  concerned  in  it,  or  at 
least  more  so ;  sometimes  the  voices  of  the  two  ears  have  a 
different  character.  A  patient  asserted  that  the  voices  went 
in  at  one  ear  and  out  at  the  other.  Many  patients  hear  the 
voices  in  the  whole  body  ;  the  spirits  scream  in  the  belly,  in 
the  feet,  and  possibly  also  wander  about ;  a  patient  heard 
them  speaking  in  his  purse.     Another  wrote  down : — 

Voice  in  the  right  ear :  "  Never,"  for  example  as  answer  to  a  wish. 
Voice  in  the  left  ear:  "Stupid — Jesus — God."  \'oice  in  the  stomach: 
"  Blackguard.  Point.  Good."  \'oice  in  the  nose  :  "  Munich ;  Oho- 
boy."  Voice  at  tfie  heart :  "  Boy."  Voice  in  the  right  side  of  the 
abdomen  :  "  Yokel." 

But  for  the  most  part  the  origin  of  the  voices  is  sought 
for  in  the  external  world.  The  patient  feels  himself  influenced 
by  the  telephone,  is  a  "living  telephone";  "it  all  came  by 
telephone  to  the  bed ";  said  a  patient.  The  question  is 
about  the  "  address,"  about  "  the  communicated  voices  of 
human  bemgs,"  about  "  murmurings  and  natural  spirit- 
voices,"  about  underground  voices  from  the  air,  from  the 
ground,  voices  from  Further  India  and  Siberia,  whispering 
voices  from  the  whole  of  mankind,  "  voices  of  spirits  which 
are  quite  near,"  of  God,  the  saints  and  the  blessed,  of  the 
guardian  angel,  but  especially  of  all  conceivable  persons  in 
the  neighbourhood.  A  patient  heard  a  bird  whistle  from  a 
picture  ;  another  saw  threads  from  which  voices  spoke.  Often 
the  voices  torment  the  patient  the  whole  day  long,  and  at 
night  also  he  hears  "  telephone  gossip,"  or  perhaps  he  only 
hears  them  now  and  then,  not  infrequently  in  the  form  of 
single  detached  remarks. 

It  is,  however,  usually  difficult  to  get  trustworthy  accounts 
of  these  occurrences  from  the  suspicious  and  reserved  patients ; 
they  usually  deny  that  they  still  hear  voices,  and  only  allow 
on  pressure  that  yesterday  or  the  day  before  perhaps  some- 


PSYCHIC  SYMPTOMS  9 

thing  happened.  Sometimes  the  patients  are  only  able  to 
give  general  information  about  the  voices  :  "  They  were  voices 
as  if  the  battle  was  lost,"  "  as  if  I  had  set  about  something  "; 
"  the  conversation  was  about  the  king  and  royalty,"  "  of  life 
and  the  soul  and  divine  love,"  of  "  marriage  and  death  ";  "  the 
clergyman  whispered  something  into  my  ear,  that  could  not 
be  understood."  But  much  more  frequently  they  catch  the 
exact  wording  as  in  real  perceptions  ;  some  patients  make 
notes  of  what  they  hear. 

What  the  voices  say  is,  as  a  rule,  unpleasant  and  dis- 
turbing. "  The  voices  rushed  in  on  me  at  all  times  as 
burning  lions,"  said  a  patient.  The  patient  is  everywhere 
made  a  fool  of  and  teased,  mocked,  grossly  abused,  and 
threatened.  People  speak  about  him  ;  everyone  is  occupied 
with  him  ;  the  whole  workshop  screams ;  there  is  "  a  petty 
espionage,"  "like  legal  proceedings";  he  hears  voices,  "as 
one  reads  of  them  in  stories  of  murder  and  Indians."  Some 
one  calls  out :  "  Rascal,  vagrant,  miserable  scoundrel," 
"incendiary,  parricide,"  "good-for-nothing,"  "blackguard," 
"anarchist,  rogue,  thieving  murderer,"  "filthy  fellow,  filthy 
blockhead,  filthy  beast,"  "vagabond,"  "scamp,"  "swine," 
"  filthy  swine,"  "  sloven  fury,''  "  town  whore,"  "  convict," 
"criminal,  criminal,"  "offended,  offended."  The  patient  is 
said  to  have  assaulted  a  child,  seduced  a  girl  with  80,000 
marks,  had  sexual  intercourse  with  his  children,  eaten  human 
flesh.  He  is  threatened  with  having  his  ears  cut  off",  his  feet 
chopped  off",  with  being  sawn  asunder,  with  being  beheaded  ; 
there  is  a  command  from  the  Government  to  stab  him.  "  He 
must  come  along  ;  he  must  be  arrested ;  he  has  seduced  the 
girl,"  it  is  said:  'That's  he,"  "I've  got  him,"  "Wait, 
Kaiser  Franz,  we've  got  you!"  "The  fellow  must  go 
to  the  cemetery,"  "  I'll  shoot  the  convict  through  the  wall," 
"  J!lst  come  along,  and  you'll  be  killed,"  "  Now  we've  given 
him  a  shot,"  "We'll  do  for  him,  he  must  come  here,"  "We'll 
squirt  water  on  him,  we'll  stab  him,"  "  He'll  be  milked," 
"  There'll  be  an  end  put  to  the  blackleg's  children,"  "  The 
beast's  going  to  die,  she's  going  to  be  fetched  down,  this 
creature."  Most  frequently  they  are  indecent  and  filthy 
things  that  are  called  out  in  which  impurity  and  self-abuse 
play  a  large  part.  In  many  of  the  utterances  a  certain 
feeling  of  disease  comes  to  light.  His  comrades  whisper 
secretly  about  the  patient,  saying  that  he  is  mentally  affected, 
"  an  absolute  fool,"  "  He  is  studying,  he  has  something  in  his 
head,"  "  He  has  neurasthenia,"  "  That  is  megalomania,"  "  He 
must  go  the  madhouse." 

On  the  other  hand  there  are  also  frequently  ^^  good  voicesl^ 


lo  DEMENTIA  PRyECOX 

"good  wishes,"  ''praise,"  "That's  the  real  Simon  Pure."  God 
makes  known  to  the  patient  that  he  will  proclaim  him,  send 
him  into  the  world  as  his  son.  "  Here  he  is,"  cries  a  voice 
from  heaven.  He  hears  that  he  is  a  king's  son,  an  officer's  son, 
that  Ue  is  very  musical ;  he  has  a  splendid  life ;  "  To-day 
we  won't  do  anything  to  him."  The  voice  calls  out :  "  King, 
King  ! "  "  Saint  Joseph  !  "  "  I  am  God  ";  a  dove  says  at  night : 
"  You  have  already  the  divine  bride." 

Many  of  the  voices  make  remarks  about  the  thoughts  and 
the  doings  of  the  patient :  "  He  has  good  hearing,"  "  Damn  it, 
what  ears  the  fellow  has!"  "He  has  done  for  himself;  the 
filthy  fellow  must  get  away  from  this,"  "  Do  you  hear  the 
reflector  upstairs  ?  Now  they  have  the  sound-hole  open 
again  ":  "  Mary,  you're  talking  nonsense,  the  policeman  has 
seen  you  already,"  "  But  what  have  we  done  to  him  ?  He 
never  listens  to  us  now,"  "  The  voices  knew  what  I  did," 
said  a  patient.  Another  when  she  exposed  herself  to  the 
sun  heard,  "  She  is  melting  ";  to  one  patient  the  voices  named 
the  people  he  met,  "analysed  his  inside."  They  narrated 
events  in  his  life,  asked  him  about  family  affairs.  "The 
director  and  the  nuns  disturb  my  rest  at  night,  they  tell  me 
all  that  has  happened  in  my  life,"  complained  a  patient. 
"  When  I  leave  the  house  all  the  telephones  know  where  I  am 
going  and  what  I  am  thinking  of:  the  whole  town  is  in 
excitement  when  I  go  out,"  said  another.  A  patient  who 
later  became  quite  insane  furnished  the  following  notes : 

"  In  the  Prince  Charles  I  should  have  got  a  shilling  tip — I  should 
have  been  a  conceited  boy— The  man  would  have  been  on  his  travels — 
Now  the  boy  too  is  still  laughing — Now  Id  just  like  to  know  why 
the  boy  is  here — He's  not  yet  at  an  end — Now  I  don't  like  it  any 
more  —  O  God!  I'm  sorry  for  the  boy— He  does  write  well — That 
goes  on  swimmingly  —  How  well  that  all  agrees — He  writes  each  line 
in  a  different  writing  (The  writing  was  really  quite  changed.) — iThe 
Jew  can't  help  himself  any  more  for  discontentment — ". 

Often,  however,  in  the  beginning  of  the  disease  or  in 
the  more  advanced  stages  what  the  voices  say  is  indifferent 
or  quite  nonsensical  and  incomprehensible.  The  patient 
hears  a  call  from  England  that  he  is  to  pay  a  visit,  "always 
another  way  about,  always  new  names";  he  hears  "Banker, 
rich  farmer,  crash,  salt  roll ";  "  Stallion,"  "  They  help  me 
or  they  don't  help  me,"  The  military  come  to-morrow  early," 
"  Education,"  "  Lavender  and  crossroads  are  the  stronge.st 
explosive,"  and  similar  expressions. 

From  the  very  varied  notes  of  a  patient,  who  was  quite 
sensible  and  rea.sonable,  I  give  the  following  example  taken 
at  random — notes  of  his   hallucinations  which   consisted  of 


PSYCHIC  SYMPTOMS  ii 

detached  sentences  without  connection,  of  the  meaning  of 
which  in  detail  he  was  not  able  to  give  any  account : — 

"She  is  said  to  have  run  after  him — Oh  you  blockheads  I  always 
hear  something  and  see  nothing — I  would  just  make  a  start — Get 
out  with  your  trash — We  have  done  our  duty  ;  now  he  can  do  what 
he  likes — It  won't  be  finished  immediately;  if  it  goes  far  wrong,  the 
law  is  still  there— Get  yourself  licked  at  A.  ;  here  you  must  have  two 
ears,  in  at  the  one,  out  at  the  other,  here  the  heirs  can  still  wrangle, 
here  twenty  shillings,  there  twenty  shillings,  yes,  why  not? — How  is  he 
ever  to  think  of  it  ;  for  he  doesn't  know  what  has  happened— d'ye  see 
him — shall    we    send    him    a    servant— A    tree    isn't    hewn    down    so 

Quickly  ;    it   did    not   grow   all   at  once,  at  night  all  cows  are   black — 
heating  innkeepers — O,   du  mein  lieber  Augustin,  's   Geld   ist  hin — 
Trees  and  the  roots  with  them — Oh  I  must  undress,"  and  so  on. 

Another  patient,  also  quite  reasonable,  wrote  down  the 
following  words  as  being  what  the  voices  said  : — 

"  He — veni  —  I  came—  Cham — Saul  —  Absalom — lyric — dropping  — 
roast  —  lust — Turks  —  rukidiku — trilling— singing — tins — tinker  —  skr — 
ram — fail — dog — fruit  — Ko — vault — complaint — flax— holy  water — pasture 

—  inspired — drone — dull — pressing — funnel — Druid — tremens — squeezing 
— dropping — quail— clever — formerly — sausage  —  lynx — vult— question  — 
crime — splendour." 

In  some  places  "  veni — kam — Cham,"  "  Saul — Absalom," 
"  trilling — singing  " — "  tins — tinker,"  there  is  a  certain  con- 
nection, if  only  external,  of  the  ideas  which  follow  each 
other.  But,  except  for  these,  the  words  are  connected 
without  any  obvious  link  of  ideas  or  sound  ;  at  most  the 
slight  similarity  of  sound  in  "  roast — lust "  and  in  the  series 
"  drone  "  to  "  dropping  "  [in  German,  Drohne — triibe — drangen 

—  Trichter  —  Druide  —  tremens — driicken  —  tropfeln]  could 
be  regarded  as  the  connecting  link.  This  series  reminds 
one  of  similar  inventions  of  alcoholics  in  delirium  when 
they  read  from  a  blank  sheet  of  paper ;  and  in  reading 
during  dreams  such  expressions,  wholly  without  connection, 
occur. 

Many  patients  hear  perpetually,  in  endless  repetition  or 
with  slight  changes,  the  same  meaningless  sentences,  so 
that  there  is  a  kind  of  hallucinatory  verbigeration.  The 
following  notes  give  an  example  of  it.  They  were  written 
down  by  an  otherwise  thoroughly  clear  and  intelligent 
patient : — 

"  For  we  ourselves  can  always  hope  that  we  should  let  ourselves  pray 
other  thoughts.  For  we  ourselves  wish  to  wish  to  know  who  would  let 
the  swine's  head  be  tormented  to  death  with  us  foolishly.  No,  we  our- 
selves are  no  longer  so  stupid,  and  do  not  always  trouble  ourselves,  if  we 
shall  let  ourselves  be  spared  drinking  like  beasts.  Because  we  just 
behave  as  fools  and  would  let  ourselves  be  cheated  like  silly  swine." 

In  a  series  of  cases  the  voices  give  commands  which  in 
certain     circumstances    are    very    precisely   obeyed.       They 


12  DEMENTIA  PR^ECOX 

forbid  the  patient  to  eat  and  to  speak,  to  work  to  go  to 
church  ;  he  must  run  barefoot.  "  Go  on,  strike  him,  beat 
him,"  it  is  said,  "go  on,  go  on!"  "Hands  up!"  "Slope 
arms!"  "Put  the  chair  here,  stand  up!"  "Jump  in!" 
A  patient  said  that  he  heard  :  "  You  must  do  that,"  then 
"  You  must  not  do  that  "  ;  "  it  is  a  chaos,  one  can't  get  out." 

But  it  is  quite  specially  peculiar  to  dementia  praecox  that 
the  patients'  own  thoughts  appear  to  thevi  to  be  spoken  aloud. 
In  the  most  varied  expressions  we  hear  the  complaint  of  the 
patients  constantly  repeated  that  their  thoughts  can  be  per- 
ceived. They  are  .said  loud  out,  sometimes  beforehand,  some- 
times afterwards  ;  it  is  "  double  speech,"  the  "  voice  trial," 
"  track-oratory,"  the  "  apparatus  for  reading  thoughts,"  the 
"  memorandum."  A  patient  heard  her  thoughts  sounding  out 
of  noises.  In  consequence  of  this  everything  is  made  public. 
What  the  patients  think  is  known  in  their  own  homes  and  is 
proclaimed  to  everyone,  so  that  their  thoughts  are  common 
property.  "  I  have  the  feeling,  as  if  some  one  beside  me  said 
out  loud  what  I  think,"  said  a  patient.  "  As  soon  as  the 
thought  is  in  my  head,  they  know  it  too,"  explained  another. 
"  When  I  think  anything  I  hear  it  immediately,"  said  a  third. 
People  look  into  the  brain  of  the  patient,  his  "  head  is 
revealed."  When  he  reads  the  newspapers,  others  hear  it,  so 
that  he  cannot  think  alone  any  longer.  "  We  can  read  more 
quickly  than  you,"  the  voices  called  out  to  a  patient.  "  Every- 
one can  read  my  thoughts,  I  can't  do  that,"  complained  a 
patient.  Another  said,  "  A  person  can  have  his  thoughts 
traced  by  another,  so  that  people  can  learn  everything."  A 
patient  himself  had  "  to  whistle "  his  secrets  "  through  his 
nose." 

Influence  on  Thought. — Still  more  characteristic  of  the 
disease  which  is  here  discussed  seems  to  be  the  feeling  of 
one's  thoughts  being  influenced,  which  often  occurs.  People 
speak  to  the  patient  in  his  thoughts,  guide  them,  contradict 
him,  "offer"  him  thoughts,  suggest  them  to  him,  transfer  to 
him  words,  thoughts,  pictures,  smells  and  feelings.  A  patient 
said,  "  My  senses  dont  belong  to  me  any  more,  they  are 
being  unlawfully  taken  from  me."  Strangers  send  him 
thoughts  silently  and  speak  in  his  head,  it  is  "  a  remembrance, 
a  memory,  a  memorial,"  a  "receiving  of  thoughts."  In  this 
way  his  own  thoughts  are  disturbed,  "drilled,"  "  drawn  off"  ; 
he  cannot  think  when  the  voice  speak.s.  A  patient  explained, 
"  They  take  my  thoughts  from  me  and  nothing  comes  back 
but  a  ragamuffin."  What  he  thinks  himself  is  distorted  ;  his 
thoughts  are  "  plundered,  organi.sed  and  published."  "  The 
voices  and  my   brain  are  one,  I  must  think  what  the  voice 


PSYCHIC  SYMPTOMS  13 

says,"  said  a  patient,  and  a  woman  complained  ;  "  The  voices 
work  on  my  thoughts  from  morning  to  evening,  suggest 
dreams  to  me  and  torment  me  unceasingly."  Many  of  the 
patients  must  utter  aloud  their  own  thoughts  or  those  that  are 
given  to  them,  "  low  by  movements  of  the  lips,"  "  say  silly 
stuff  to  oneself."  "  It  flows  into  the  brain  as  a  thought  and 
expresses  itself  as  words  in  the  mouth,"  said  a  patient. 
Another  heard  "  dead  "  and  had  to  answer  "  bread." 

On  the  other  hand  the  patient  sometimes  knows  the 
thoughts  of  other  people,  is  "  connected  by  telephone  with 
M'Kinley,"  can  "  speak  with  the  Kaiser,"  "  tones  constantly 
with  God,"  "  is  in  constant  communication  with  the  Holy 
Ghost."  He  can  also  think  for  others, he  passes  on  the  thoughts, 
carries  on  conversations,  dialogues,  with  his  companions^ 
with  people  in  other  houses  ;  it  is  an  "  electrical  glee." 
"  There  is  talking  going  on  in  my  head  and  body,"  said  a 
patient.  "  I  close  my  throat  and  sing  the  most  beautiful 
songs,  and  you  do  not  hear  it." 

These  most  extraordinary  disorders,  quite  foreign  to 
healthy  experience,  are  at  first  usually  kept  secret  by  the 
patient,  so  that  one  only  hears  something  about  them  when 
they  have  already  existed  for  a  long  time.  The  patients 
frequently  connect  them  with  malevolent  people  by  whom 
they  are  "  watched  through  the  telephone,"  or  connected  up 
by  wireless  telegraphy  or  by  Tesla  currents.  Their  thoughts 
are  conveyed  by  a  machine,  there  is  a  "  mechanical  arrange- 
ment," "  a  sort  of  little  conveyance,"  telepathy.  A  patient 
said,  "  I  don't  know  the  mati  who  suggests  that  to  me." 
Another  supposed  that  it  might  perhaps  be  done  for  scientific 
purposes  by  a  professor.  vA  third  explained,  "  I  am  perfectly 
lY  >sane  and  feel  myself  treated  as  a  lunatic,  whjleTTaTTucinatlohs 
are  "brougKt  to  me  by  magiietlsifnSncl  erectriclty."^  Or  thff" 
patients  think  of  supernatural  powers,  of  "  demi-spirits  which 
perceive  the  thoughts,"  "  little  souls  and  little  figures,"  their 
guardian  angel,  God  and  Christ ;  they  are  inspirations,, 
revelations.  A  patient  heard  the  unborn  Virgin  Mary  speak 
in  his  belly  ;  another  carried  God's  voice  in  his  heart. 

Many  patients  feel  themselves  very  much  troubled  by 
telephony,  they  stop  their  ears,  "  do  not  like  such  treatment 
by  voices."  One  patient  begged  that  "  the  blessed  nonsense 
should  be  taken  away."  Others  regard  themselves  as 
specially  privileged.  "  I  hear  from  a  distance  ;  not  everyone 
can  do  that,"  said  a  patient.  Some  patients  try,  by  ingenious 
devices,  to  protect  themselves  against  their  thoughts  being 
influenced  ;  a  patient  translated  foreign  words  in  order  to 
ward  off  the  receiving  of  thoughts.     Others  exert  themselves 


14  DEMENTIA  PRECOX 

to  conceal  their  real  line  of  thought  to  a  certain  degree,  by 
a  second  carried  on  alongside  of  it,  which  shall  then  receive 
the  outside  influences. 

Hallucinations  of  sight  begin  with  variegated  rings  in 
front  of  their  eyes,  plays  of  colour,  fiery  rays  and  balls,  seeing 
sparks,  everything  looks  awry  and  wrong.  The  patients  are 
troubled  by  reflections,  by  blinding  light,  their  eyes  are 
irradiated  and  blinded  by  reflectors.  On  the  wall  appear 
white  figures,  reflections,  the  mother  who  is  dead,  paintings, 
imaginative  pictures,  death's  heads,  a  heart  with  a  dagger, 
ghosts,  shadow  figures  half  beast,  half  human,  southern 
landscapes,  saints  from  all  eternity  ;  it  is  photography  at  a 
distance  and  double  sight.  In  front  of  the  window  a  clown  is 
tumbling  about,  good  and  evil  spirits  appear,  angels  and 
the  Virgin  Mary  in  a  blue  mantle  offer  the  cup,  Satan  with 
horns  and  a  fiery  tail  dances  about  the  room,  death  appears 
as  a  figure  with  a  mask ;  at  night  men  approach  the  bed. 
Black  birds  of  prey  hover  overhead ;  people  appear  who  are 
not  there;  the  Emperor  ofChina comes  and  speaks;  gentlemen 
in  white  suits,  lions,  people  who  are  dead,  pretty  girls,  red 
men  with  black  heads  appear ;  a  black  figure  grins.  The 
patient  sees  "  a  shining  crown  and  a  threatening  star," 
"  theatrical  stuff,"  naked  women,  improper  pictures,  an 
automobile  in  the  air,  two  men  in  a  balloon,  the  "  Wild 
Hunt"  ;  a  green  shadow  flies  beside  him.  There  are  snakes  in 
his  food,  in  the  water  for  his  bath.  Supernatural  appearances 
are  seen  in  the  air,  fire  in  the  sky,  a  halo,  Luther  in  the 
clouds,  spirits  in  the  fields.  Acquaintances  look  strange, 
everything  is  as  though  accentuated,  pieces  of  furnitnre  are 
changed  into  the  form  of  wife  and  children  ;  the  figures  in 
paintings  and  sculpture  make  obeisance.  A  patient  saw  the 
"  voices  "  in  the  form  of  small,  grey,  four-footed  beings  hopping 
round  about  and  whirling  in  the  air  ;  they  were  accompanied 
by  small  flames,  which  could  be  separated  from  them, 
Another  offered  in  a  very  definite  way  "  extrakampine  " 
hallucinations;  he  "  saw  "  a  gun-barrel  on  his  back,  led  and 
white  mice  in  his  heart,  two  tortoises  in  his  shoulder. 

Smell  and  taste  frequently  share  in  the  morbid  condition. 
Evil  smelling  substances  are  scattered  about;  there  is  a  smell 
of  sulphur;  of  corpses  and  chloride  of  lime,  of  blood,  of  fire, 
of  the  fumes  of  hell,  of  "stinking  poison,"  of  dynamite.  A 
patient  smelled  human  souls ;  another  felt  the  devil  standing 
behind  her,  '  it  stank."  Cold  vapours  are  blown  in  at  the 
one  nostril,  warm  vapours  at  the  other.  Many  patients  smell 
the  fragrance  of  roses,  or  notice  that  they  are  being 
chloroformed  or  stupefied  by  perfumed  handkerchiefs.     The 


PSYCHIC  SYMPTOMS  15 

soup  has  a  curious  taste  of  creosote  ;  in  the  food  there  is 
petroleum  or  arsenic,  in  the  beer  morphia  or  iodoform,  the 
drinking  water  is  brackish,  or  contains  chloroform. 

Morbid  tactile  sensations  and  common  sensations  mean- 
while gain  considerable  importance  in  the  clinical  picture. 
They  are  usuall)  very  varied.  The  patient  feels  himself  laid 
hold  of,  touched  over  his  whole  body,  he  feels  tickling  in  his 
thigh  and  right  up  to  his  neck,  pricking  in  his  back  and 
in  his  calves,  a  curious  feeling  in  his  neck,  heat  in  his 
face  ;  hot  sand  is  strown  over  his  face,  filth  is  put  in  his 
hair;  something  is  squirted  on  his  feet;  a  hundred  mice  run 
over  his  neck.  At  night  he  is  pricked  with  needles,  he  gets 
blows  in  the  ribs,  invisible  powder  is  sprinkled  over  him  ; 
warm  air  plays  on  his  body.  He  has  a  feeling  as  if  his  feet 
were  rising  from  the  ground  ;  his  bed  is  pushed  at  night, 
moves  about,  swings.  Vermin  and  itch  powder  are  in  his 
bed  ;  a  patient  felt  lion  cubs.  There  is  a  tearing  feeling  in 
his  head  and  in  his  back,  a  burning  in  his  stomach,  pain  in 
his  teeth,  a  rolling  in  his  brain,  a  tugging  at  his  heart,  lumbago 
shoots  through  his  body  and  loins.  A  patient  felt  it  in  his 
right  ear,  if  other  people  turned  up  their  noses. 

Not  infrequently  these  imaginations,  connected  apparently 
with  organic  sensations,  receive  a  very  strange  interpretation. 
The  patient  is  terribly  tormented  in  his  body,  notices  that 
something  is  taken  away  from  him,  blood  is  taken,  that 
"every  part  of  his  body  is  misused";  he  feels  "internal 
stirrings."  emptiness  inwardly,  currents  and  strains  in  his 
body.  Water  flows  away  out  of  his  body,  food  goes 
immediately  out  at  his  head.  His  body  is  twisted  ;  his 
mouth  is  torn  asunder ;  his  gums  are  broken  open  ;  his  eyes 
are  clawed  out ;  his  hair  is  tugged  out ;  his  shoulders  are 
pulled  apart,  his  testicles  are  burst ;  her  ovaries  and  stomach 
are  torn  out ;  his  cheeks  are  pared  off.  His  brain  is  crushed, 
his  throat  is  blown  out ;  his  whole  intestine  is  drawn  up  ;  fire 
bursts  out  at  his  mouth.  The  patient  has  injections  made 
behind  ;  God  pierces  his  foot  with  a  wire  ;  he  is  disfigured. 
A  man  is  laid  across  him,  his  back  is  broken,  his  breath  is 
sucked  up.  Ears  and  head  are  blown  up,  his  strength  is 
drawn  out,  his  toes  are  burned  off,  his  ears  are  cut  off.  A 
patient  kept  saying  that  he  was  being  "deprived,"  another 
that  he  was  being  "undone."  A  third  complained  of  "inter- 
sections ";  a  fourth  said,  "  It  is  always  as  if  something  were 
being  shoved  into  me,"  a  fifth  felt  "  a  thousand  dolls  sliding 
down  inside  him." 

Very  commonly  these  sensations  are  associated  with 
electricity  and  similar  action  at  a  distance.     The  patient  feels 


i6  DEMENTIA  PR/ECOX 

himself  fastened  to  the  receiving  and  also  to  the  discharging 
station,  electrified  from  a  distance,  raised  from  the  ground  by 
electric  shocks,  blown  up  by  electricity,  he  feels  the  current  in 
his  pleur.t,  a  prick  in  his  heart  from  the  apparatus,  he  becomes 
warm  by  the  rays  ;  electric  currents  flow  through  his  bed  ;  an 
electric  current  comes  from  the  sun.  A  patient  thought  that 
she  was  illuminated  with  Rontgen  rays  under  her  petticoats 
and  was  thus  exposed  to  the  general  gaze. 

As  the  result  of  these  hallucinations  the  conviction  is 
often  developed  in  the  patients  that  they  have  become  the 
sport  of  all  sorts  of  influences}  A  patient  described  this  in 
writing  in  Lhe  following  words  : — 

"  I  felt  myself  touched  in  such  a  way  as  if  I  were  hypnotised, 
electrified,  or  generally  controlled  by  some  sort  of  medium  or  some  other 
will.  My  several  organs  of  sense  were  influenced  in  such  a  way,  that  I 
always  heard  the  will  of  the  medium  from  great  distances,  to  which  I  had 
then  unconditionally  to  surrender  myself  I  feel  and  hear  the  will  in 
all  parts  of  my  body,  in  my  whole  organism.  I  must  do  what  I  hear 
according  to  the  will  of  the  so-called  medium  which  can  assume  the  voices 
of  all  people  known  to  ine,  of  whom  others  daily  appear  before  my  soul. 
In  this  way  as  regards  my  person  there  are  no  secrets  for  the  medium  as 
a  whole.  Ail  that  has  passed  through  my  brain,  or  that  still  influences  it, 
is  reproduced  by  the  medium,  and  indeed  as  often  as  it  likes,  and  my 
brain  has  always  to  take  part  in  this  proceeding,  which  extends  not  only 
to  thoughts  but  also  to  speech.  The  characteristic  feature  is  that  I 
also  have  these  hallucinations  of  hearing  when  my  hearing  is  deafened 
by  a  real  noise,  so  that  I  am  sure  that  these  proceedings  take  place  in 
the  brain  itself  I  have  also  already  had  hallucinations  of  sight,  visions,^ 
and  all  this  happens  according  to  the  will  of  the  medium  and  as  a 
consequence  of  my  power  of  imagination.  The  visions  only  appear 
when  I  have  my  eyes  closed." 

Notice  here  the  curious  mixture  of  insight  into  disease 
and  ideas  of  influence,  but  especially  the  feeling  of  internal 
compulsion,  which  we  shall  meet  with  again  and  again  in  our 
descriptions. 

Sexual  sensations  play  a  considerable  role  in  our 
patients'  experiences.  The  patient  has  a  feeling  of  contraction 
in  the  testicles  and  penis,  experiences  "  a  sultry  feeling  "  on 
meeting  people,  notices  signs  in  his  fingers  which  the  girls 
make.  Love-charms  are  employed,  the  penis  is  erected  by 
the  electric  current,  a  gold  needle  is  stuck  into  it.  At  night 
lustful  deeds  are  committed,  his  nature  is  electrically  with- 
drawn from  him ;  lustful  men  approach  him.     A  patient  felt 

'Haslam,  Erklarungen  dcr  Tollheit,  Ubersetzt  von  Wollny,  1889;  Wollny  j 
Uber  Telepathic,  1888;  Sammliing  von  AktenstUcken.  1888;  Teffer,  Ul>er  die 
Tatsache  des  psyclio  sexuakn  Kontaktes  oder  die  actio  in  Distans.  1891  ; 
Schreber,  E>enkwlirdigkeiten  eines  Nervenkranken.  1903. 


PSYCHIC  SYMPTOMS  17 

that  she  was  kissed  at  night  by  a  Capuchin.     Another  patient 
described  her  experiences  at  night  in  the  following  way  : — 

"It   seemed   to   me   in   the   night   as   though    I    were  divinely   and 

spiritually  married,  or  rather  that  my  innocence  was  taken  from   me. 

The  pains  were  considerable,  but   I   did  not  scream   though  for  some 

minutes  I  had  to  breathe  violently.     It  then  seemed  to  me  as  though  I 

,were  several  times  married,  when  I  had  to  lie  down  on  the  bed  with 

'  better  clothes  on.     But  there  never  was  a  human  being  with  me." 

Orientation  is  not  usually  disordered.  The  patients 
know  as  a  rule  where  they  are,  recognize  people,  are  clear 
about  the  reckoning  of  time.  It  is  only  in  stupor  and  in 
states  of  intense  anguish  that  the  correct  perception  of  the 
environment  may  occasionally  be  more  profoundly  disordered. 
Jt  is  indeed  often  just  the  characteristic  of  th^  p^^^ipntt;  that 
they  remain  surprisingly  clear  m  spite  of  the  most^iolcUir 
excitement.  On  the  otReFhand,  however,  orientation  Is  not 
iiifrequeiTtly  encroached  upon  by  hallucinations.  The  patients 
name  their  place  of  residence  and  persons  incorrectly,  give  a 
wrong  date,  are  in  a  wrong  hospital,  in  an  imitation*  madhouse, 
in  a  prince's  house ;  the  physician  is  God,  the  attendant 
Satan  ;  his  relatives  have  been  exchanged,  his  fellow  patients 
are  females  or  disguised  policemen.  But  here  it  is  clearly 
not  a  case  of  falsification  of  perception  but  of  insane 
interpretation  of  impressions  in  themselves  correctly  per- 
ceived. 

.  The  consciousness  of  the  patients,  if  we  leave  out  of 
account  the  terminal  condition  of  dementia,  is  in  many  cases 
clear  throughout.  Only  in  conditions  of  excitement  and 
stupor  is  It  occasionally  dulled,  though  the  dulness  is  not 
'usually  so  great  as  it  appears  at  the  first  glance.  The  patients 
complain  frequently  of  passing  dulness  of  consciousness 
which  should  probably  be  regarded  as  a  condition  of  very 
slight  stupor.  They  say  that  they  were  "  stunned,"  "  dis- 
embodied, magnetically  repressed ";  they  became  suddenly 
incapable  of  thinking  or  of  working.  These  are  "  mental 
conditions  artificially  induced  through  hypnosis,"  "spiritual 
visitations,"  "  magnetic  condittnns  ot  sieep.^^  caused  by  the 
physician*  A  pa'tlenfthought  he  suffered  from  "somnam- 
bulism " ;  another  narrated  about  the  "  nightly  narcosis 
with  Rontgen  in  which  she  was  cross-questioned  ;  it  would 
all    appear  in  the   newspaper  in   which  people   would   hear 

wabout  it." 

v       Memory^  is  comparatively  little,  disordered.    The  patients 
are  able,  when  they  like,  to_give  a  correct  detailed  account 
of  their  past  life,  and  often  know  accurately  to  a  day  how 
1  Gregor  und  Hansel,  Moratsschr.  f.  Psychiatric,  xxiii.  i. 


i8  DEMENTIA  PR/ECOX 

long  they  have  been  in  the  institution.  JThe  knowledge 
which  they  acquired  at  school  remains  Sometimes  with 
surprising  tenacity  until  they  are  sunk  in  the  most  profound 
dementia.  |  T  remember  a  peasant  lad,  mentally  quite  dull, 
who  could  point  to  any  town  on  the  map  without  hesitation. 
Another  startled  you  by  his  knowledge  of  history.  Others  * 
again  solve  difficult  problems  in  arithmetic  with  ease.  1 
Weygandt  ascertained  that  a  prebendary  of  the  Julius 
Hospital,  who  suffered  from  mental  disease  and  was  quite 
confused,  still  retained  forty-seven  years  after  the  beginning 
of  his  illness  a  fair  knowledge  of  Latin,  mastery  of  the 
multiplication  table,  and  also  recollected  all  sorts  of  historical 
facts,  although  these  ideas  had  certainly  not  been  roused 
for  decades. 

Retention  is  also  often  quite  well  preserved.  Gregor 
however,  found  in  his  experiments  very  dissimilar  values  for 
successive  repetitions  in  consequence  of  great  wavering  of 
attention.  Mistakes  and  senseless  combinations  were  not 
corrected,  'but  rather  showed  an  inclination  to  become 
established  ;  continuance  of  the  repetition  was  of  com- 
paratively little  use.  Vieregge  also  reports  great  wavering 
of  attention.  In  spite  of  that  it  is  usually  easy  to  impress 
numbers  or  names  even  on  quite  indifferent  patients,  which 
they  correctly  reproduce  after  days  and  weeks.  llCertainly 
inappropriate  answers  are  often  given  first,  but  after  more 
searching  interrogation  it  is  clear  that  the  patients  have  quite 
understood  the  exercise.  I  After  deep  stupor  it  sometimes 
happens  that  the  patients  have  no  recollection,  or  only  a  very 
dim  recollection,  of  what  has  occurred  during  a  long  space  of 
time,  it  may  be  that  because  of  the  dulness  of  consciousness, 
they  were  unable  to  perceive,  or  that  the  impressions  were  not 
permanent. 

Pseudo  -  memories. — Here  and  there  we  meet  also  with 
confabulations  which  point  to  pseudo-memories.  It  must,  it 
is  true,  seem  very  doubtful  if  one  ought  to  speak  of  such  when 
the  patients  relate  that  they  have  been  in  hell,  in  heaven,  in 
America,  have  travelled  over  the  moon  and  all  parts  of  the 
world,  that  at  six  years  of  age  the  marrow  was  burned  out  of 
their  legs,  and  their  feet  were  chopped  off".  A  patient 
declared  that  he  had  already  been  beheaded,  but  his  head  had 
not  fallen  off".  In  other  cases,  however,  it  is  easier  to  assume 
pseudo-memories.  The  patient  remembers  having  been  in  a 
beautiful  castle  as  a  little  child  and  having  sat  on  the  knee  of 
a  grand  gentleman,  and  to  have  been  kidnapped  on  a 
cloudy  night.  Kaiser  VVilhelm  on  a  journey  through  the 
town  gave  him  a  medal  which  in  an  unaccountable  way  has 


PSYCHIC  SYMPTOMS  19 

been  mislaid.  Others  assert  that  they  already  knew  before- 
hand where  they  were  to  be  brought,  and  what  would  happen, 
that  in  the  madhouse  they  would  meet  this  and  that  person, 
that  there  would  be  a  fire,  and  they  would  get  a  bride.  A 
patient  asserted  that  the  Spirit  had  prophesied  to  him  the 
death  of  an  acquaintance  ;  another  explained  that  God 
inspired  him  so  that  he  could  foretell  what  should  happen. 
Or  the  patients  think  that  they  have  already  been  in  the  hall, 
that  they  have  seen  the  pictures  before ;  they  consulted  the 
physician  once  two  years  ago.  A  patient  declared  he  had 
himself  planted  the  trees  in  the  hospital  garden.  Usually  the 
tendency  to  such  insane  pseudo-memories  passes  off  quickly. 

Train  of  Thought. — This  sooner  or  later  suffers  consider- 
ably. There  is  invariably  at  first  a  /oss  of  inetital  activity  and 
therewith  a  certain  poverty  of  thought.  The  patient  "  has 
little  life  in  him  ";  his  nerves  are  under  sucFT^skm^thar  he 
can  no  longeFthink  or  speak.  Thinking  is  difficult  to  him  ; 
"  he  trifles  about  the  whole  day,"  occupies  himself  "with  tear- 
ing off  the  last  leaf  of  the  calendar  and  tidying  up."  His 
thoughts  have  been  taken  out  of  his  head  ;,he  has  lost  the  joy 
of  life  ;  it  is  as  if  a  fur  cap  were  on  his  brain,  he  is  "  as  stupid 
as  a  pig ";  his  head  is  empty  and  hollow.  A  patient 
complained  that  "he  had  no  more  earnestness." 

Association  experiments. — Bouman  frequently  observed 
repetition  of  the  word  used  as  stimulus,  irrational  associations, 
omissions ;  disinclination  to  make  the  attempt  seemed  to 
lay  a  considerable  role.  Bleuler  brings  forward,  among 
thers,  as  further  peculiarities  of  "schizophrenic"  associa- 
tions, great  irregularity  of  association-time,  connecting  up 
with  former  stimuli  or  answers,  frequent  repetition  of  the 
same  associations,  tendency  to  indirect  associations,  change 
of  answer  on  repetition  of  the  experiment.  Marcus  found  in 
his  patients  specially  livelyvisual  ideas.  Further,  Pfersdorff 
has  proved  that  in  the  combination  oF  ideas  lifigtiistic  con- 
stituents gain  a  certain  preponderance  ;  the  patients  show  a 
tendency  to  rhyme,  to  intjpduce  asso!TatT£gs,  to  play  witiT 
words,  to  tmst  Hi^m,  Kehav-iour  to  winch  we  shall  later  have 
\o  return"  - 

But  above  all,  as  Bleuler  especially  has  shewn  in  detail, 
the  patients  lose  in  a  most  striking  way  the_faculty  of  logical 
ordering  of  their  trains  of  thoucrht.  On  the  one  hand,  the 
most  selt-evident  and  tamiliar  associations  with  the  given 
ideas  are  absent.  It  seems  as  if  these  were  only  partially 
illumined,  and  therefore  were  not  in  a  position  to  call  into 
consciousness  thoughts  that  lie  quite  near.  On  the  other 
hand  again,  the  most  unnatural  combinations  of  heterogen- 


20  DEMENTIA  PR/ECOX 

cous  ideas  are  formed,  because  their  incongruity  is  not 
perceived  on  account  of  some  purely  external  relation,  as 
similarity  in  sound,  or  coincidence  in  time.  The  most  evident 
truths  are  tiotrecogiiised,  the  greatest  ^coptradictions  ^e 
thoughtlessly  accepted.  "  DocTor,  Is  your  name  Julia?"  asked 
a"7^atienT7^TTff  another  called  the  physician  "Mrs  Colonel." 
By  these  disorders,  which  in  many  respects  remind  one  of 
thinking  in  a  dream,  the  patients'  mental  association*;  often 
have  that  peculiarly  bewildering  incomprehensibility,  which 
distinguishes  them  from  other  forms  of  confusion.  It  con- 
.stitutes  the  essential  foundation  of  incoherence  of  thought. 

In  less  severe  cases  this  is  shovvn~oTTty-TTrTncreased  facility 
of  distraction  and  increased  desultoriness,  in  passing  without 
any  connection  from  one  subject  to  another,  in  the  interweav- 
ing of  superfluous  phrases  and  incidental  thoughts.  Similarly, 
Pfersdorff  found  in  continuous  reading  a  tendency  to  make 
meaningless  mistakes, ^^o  perseveration  of  certain  words,  to 
changes  and  omissions7~even  when  single  words  or  short 
sentences  were  correctly  rendered  ;  he  concludes  rightly  that 
there  is  a  failure  .of  attention.  A  patient  who  was  quite 
sensible,  when  asked  to  copy  the  fable  of  the  "  greedy  dog," 
performed  the  exercise  correctly  as  far  as  the  sentence  :  "  But 
when  he  snapped  at  it,  his  own  piece  of  meat  fell  from  his 
mouth,  and  sank  in  the  water,"  then,  however,  continued  : — 

".And  as  now  her  present  condition  depends  wholly  on  what  Dr 
J.  M.  plans  for  the  future,  who  wishes  to  make  himself  acquainted  with 
what  is  in  connection  with  it,  and  of  whose  condition  she  wished  to  be 
again  acquainted  with,  which  he  wished  on  his  own  desire.  Now  he  had 
nothing  at  all  but  what  was  yours,  which  seems  to  lose  what  was  his,  but 
he  himself  tried  to  lose  it,  the  fortune  which  for  him  was  trying  to  be 
acquired,"  and  so  on. 

The  line  of  thought  here  leaves  the  appointed  exercise 
and  moves  in  indistinct  spheres  of  ideas,  which  otherwise 
occupied  the  patient,  and  then,  without  any  connection,  again 
brings  in  parts  of  the  fable  ("  Now  he  had  nothing  at  all," 
"  Who  wants  to  take  the  goods  of  others  loses  his  own  "). 
Still  more  striking  is  the  departure  from  the  given  idea  in  the 
answer  of  a  patient  who  was  asked  what  year  it  was : — 

"O  I  know  nothing,  what  shall  I  say?  Fire,  fire  !  O  you  old  beast, 
devil,  wretch,  dog,  slaughtered,  slaughtered  I  It's  cold  in  the  wood  ; 
hurrah  !     Damn  it  a  million  times,  beast  of  a  cat,  slaughtered  I " 

In  certain  circumstances  the  incoherence  may  go  on  to 
complete  loss  of  connection  and  to  confusion.  An  example 
of  this  is  given  in  the  following  answer  of  a  patient  to  the 
question  :  Are  you  ill? — 

"You  see  as  soon  as  the  skull  is  smashed  and  one  still  has  flowers 
Maughs)  with  difficulty,  so  it  will  not  leak  out  constantly.     I  have  a  sort 


PSYCHIC  SYMPTOMS  21 

of  silver  bullet  which  held  me  by  my  leg,  tiiat  one  cannot  jump  in,  where 
one  wants,  and  that  ends  beautifully  like  the  stars.  Former  service, 
then  she  puts  it  on  her  head  and  will  soon  be  respectable,  I  say,  O  God, 
but  one  must  have  eyes.  Seats  himself  and  eats  it.  Quite  excited,  I 
was  quite  beside  myself  and  say  that  therefore  there  should  be  meanness 
and  there  is  a  merry  growth  over.  It  was  the  stars.  I,  and  that  is  also 
so  curious,  the  nun  consequently  did  not  know  me  any  more,  I  should 
come  from  M.  because  something  always  happens,  a  broken  leg  or 
something,  they've  had  a  quarrel  with  each  another,  the  clergyman  and 
she  ;  a  leg  has  just  been  broken.  I  believe  it  is  caused  by  this  that  such 
a  misfortune  happens,  such  a  reparation  for  damages.  I  have  also  said 
I  shall  then  come  in  the  end  last,  with  the  sun  and  the  moon,  and  too 
much  excitement,  and  all  that  makes  still  a  great  deal  of  trouble.  Kings 
do  not  collect  the  money,  "in  this  way  the  letters  have  been  taken  away 
from  me,  as  I  at  last  specially  think  from  the  that,  and  all  are  burned. 
You  can  imagine  that  comes  always  from  one  to  the  other." 

In  a  few  places  here,  a  certain  connection  between  the 
ideas  can  perhaps  be  recognised  : — "  ill — skull  smashed,"  "  held 
by  my  leg — not  jump  in,"  "something  happens — broken  leg," 
"misfortune— reparation  for  damages,"  "excitement — trouble," 
"letters  taken  away — burned,"  "excited — quite  beside  my- 
self" Also  "silver  bullet"  and  "stars,"  and  further  on  "sun 
and  moon  "  and  "  nun  "  and  "  clergyman,"  who  "  have  had  a 
a  quarrel  with  each  other,"  point  to  associations  of  thought. 
On  the  whole,  however,  we  have  before  us  a  completely 
unintelligible  and  aimless  series  of  words  and  fragments  of 
thoughts.  It  must  certainly  be  taken  into  consideration  that 
the  actual  train  of  thought  is  possibly  much  less  disordered  than 
the  expression  of  it  in  speech,  because  the  patients,  as  indeed 
happened  in  this  case,  can  in  certain  circumstances  not  only 
perceive  correctly,  but  also  further  elaborate  what  they  per- 
ceive and  behave  fairly  rationally. 

Stereotypy. — We  almost  always  meet  in  the  train  of 
thought  of  the  patients  indicatlons^of "  stefebfypy,  oFThe 
persistence ,ot_gingIe  ideas.  If  "thfe^  patient  continues  talking, 
the  same  ideas^nd  expressions  usually  turn  up  again  from 
time  to  time.  Occasionally  the  persistence  gets  the  mastery 
of  the  train  of  thought  to  such  an  extent  that  the  patients  for 
weeks  and  months  always  move  in  the  same  monotonous 
^sphere  of  ideas,  and  cannot  be  brought  out  of  it  by  any 
means.  ~ 

Evasion.  —  Further  peculiar  disorders  of  the  train  of 
thought  which  here  and  there  are  observed,  are  evasion  and 
a  feature  which  Bleuler  more  accurately  characterised  as 
"^utdlectual  negativisvir  Evasion  or  paralogia  consists  in 
tRis,lTiat  the  Idea  which  is  next  in  the  chain  of  thought  is 
suppressed  and  replaced  by  another  which  is  related  to  it. 
It  appears  most  distinctly  in  the  patients'  answers  to 
questions  ;    but  it  might  be  possible  that  the  complaints  of 


22  DEMENTIA  PR/ECOX 

the  patients  that  their  thoughts  are  "drawn  ofl  "  from  them, 
"distorted,"  refer  to  similar  occurrences.  An  example  is 
given  in  the  following  answers  of  a  patient  to  the  physician's 
questions : — 

What  is  the  name  of  this  gentleman?  (Dr  A.),  "  Little  man."  What 
is  his  name.''  "  Floischiitz"  (The  name  of  a  fellow  patient).  How  many 
fingers  am  I  holding  up?  (3)  "Four."  How  many  now?  (4)  "Five." 
And  now?  (2)  "One."  How  much  money  is  that?  (three  pennies) 
'*  .Si,xpence."  No,  you  know  quite  well,  "Twopence,"  No,  how  much? 
"  Fourpence."  Now  name  the  number  that  was  left  out,  how  much 
then?  "Twenty-five  thousand."  What  do  you  mean  by  twenty-five 
thousand?  "That  I'm  all  right." 

It  is  here  easily  seen  that  the  patient  deliberately 
avoids  the  right  answer  which  he  certainly  has  at  his 
command,  a  proceeding  which  at  first  makes  the  impression 
of  intentional  dissimulation.  A  patient  replied  to  the 
question  how  old  she  was ;  "  One  day."  Clearly  this 
phenomenon  is  nearly  related  to  the  negativistic  disorders 
of  thought.  They  appear  in  the  difficulty  to  carry  on  a 
series  of  ideas  as  one  wishes,  the  patient's  thoughts  are 
"  taken  "  from  him.  So  it  sometimes  comes  to  pass  that  he 
is  obliged  to  think  the  opposite  of  what  he  really  wishes. 
There  are  "quarrels  in  his  head."  One  patient  said,  "My 
ideas  have  quarrelled,"  while  another,  perhaps  with  reference 
to  such  occurrences,  said,  "  Swindling  is  constantly  going  on 
in  my  inside."  This  state  appears  more  clearly  in  the 
utterances  of  other  patients,  that  they  "  are  forced  to  think 
otherwise, "  that  they  "  have  to  think  the  opposite  of  what 
other  people  with  normal  understanding  do." 

Constraint  of  Thought.  —  From  these  and  similar 
experiences  the  feeling  which  has  already  been  discussed 
often  develops  in  the  patients,  that  their  thinking  is  con- 
strained, has  been  withdrawn  from  the  dominion  of  their 
will  by  irresistible  influences.  On  the  one  hand  thoughts 
arise  in  them  which  they  feel  as  strange,  as  not  belonging 
to  themselves  ;  there  is  a  "  thronging  of  thoughts,"  a  "  pushing 
of  thoughts."  .sometimes  in  tempestuous  form.  A  patient 
had  to  "  drive  through  his  brain  in  four  hours  nineteen  jears  "; 
another  thought  he  would  have  to  write  a  book  if  he  were 
to  note  down  everything  that  came  into  his  head.  But  on 
the  other  hand  the  patients  cannot  think  as  they  wish ;  their 
thoughts  are  withdrawn  from  them,  slip  away  from  them, 
although  they  exert  themselves  to  hold  them  fast  and  to 
think  them  out.  Owing  to  this  there  can  be  a  sudden 
"blocking"  of  their  thought,  producing  a  painful  inter- 
ruption in  a  series  of  ideas. 

They  never  tire  of  describing   this  con.straint   of  theirs 


PSYCHIC  SYMPTOMS  23 

in  ever  varying  ways.  The  patient's  thoughts  are  influenced, 
inspired,  pressed  on  him ;  he  must  receive  them  like  a  tele- 
phone ;  they  are  forced  on  him  by  hypnotism  and  suggestion, 
act  on  him  "  by  suggestion."  Everything  that  he  thinks 
or  says  is  thought  or  said  under  compulsion.  A  patient 
had  always  to  fight  against  the  idea  that  he  was  Christ. 
Reading  is  interrupted  by  thoughts  and  explanations ; 
thoughts  are  arrested,  blurred,  the  patient  has  to  exert 
himself  to  squeeze  them  out ;  he  must  think  what  people 
say.  He  feels  as  if  his  brain  stood  still,  as  if  he  had  two 
brains.  He  is  no  longer  himself,  he  has  a  kind  of  double 
consciousness  ;  the  voices  pull  a  thread,  so  that  he  has  to 
think  such  stupid  things.  The  thoughts  can  be  taken  out 
of  people's  brains ;  the  patient  is  confused  in  his  head,  he 
cannot  grasp  any  clear  ideas,  he  cannot  bring  order  into 
the  jumble  of  his  thoughts,  there  is  an  "entanglement  in 
his  mind."  A  patient  wanted  to  strangle  herself  because 
she  had  not  her  thoughts  any  longer.  Thoughts  are  made 
by  others  in  the  distance,  in  Berlin,  read  off,  taken  away, 
carried  over.  "It  was  blown  into  me  that  way"  said  a 
patient.  His  thoughts  escape  from  the  patient,  he  cannot 
catch  them  up,  he  is  no  longer  independent.  A  patient  "  had 
to  speak  about  politics,"  another  had  always  to  think  of 
"  business  arrangements,"  a  third  "  had  to  despise  people." 
Frequently,  as  before  described  in  detail,  the  powers  which 
carry  out  such  thought-influences,  take  on  the  form  of  voices 
which  take  away,  turn  aside,  or  suggest  thoughts. 

Mental  efficiency  is  always  diminished  to  a  considerable 
extent.  The  patients  are  distracted,  inattentive,  tired,  dull, 
do  not  take  pleasure  in  work,  their  mind  wanders,  they  lose 
the  connection,  they  "  cannot  keep  the  thought  in  mind," 
they  have  no  perseverance.  I  It  is  true  they  are  often  able 
to  carry  out  quickly  and  correctly  tasks  depending  solely 
on,  memory  or  practice,  sums,  repetition  of  what  they  have 


previously  learned,   but  fail  completely  as   soon   as   it  is  a 


^i/ 


mentioned.  In  work  the  patients  soon  become  negligent, 
they  get  bad  certificates,  pass  no  examinations,  are  turned  off 
everywhere  as  useless,  and  easily  fall  into  the  condition. of 
beggars  and  vagabonds.  They  sit  about  idle  and  the  most  they 
do  is  to  turn  over  the  pages  of  an  old  calendar  or  to  stare 
at  the  advertisements  in  a  newspaper.  Others  develop  great 
diligence,  "  study  all  night  long,"  but  accomplish  nothing  at 
all,  take  up  trifling  or  aimless  occupations,  begin  to  compose 


24 


DEMENTIA  PR/ECOX 


bombastic,  incomprehensible  rhymes,  to  copy  a  foreign 
dictionary,  or  they  lock  themselves  up  in  order  to  learn 
poems  off  by  heart. 

Experiments  in  calculation  yield  further  insight  into  the 
changes  in  mental  efficiency.  These  experiments  were 
employed  in  a  number  of  patients  according  to  the  procedure 
formerly  employed  for  alcoholics.  Fig.  i  gives  a  graph  of 
the  results.  Here  the  work  done  in  the  first  five  minutes 
and  in  the  second  five  minutes,  on  the  days  when  no  pause 
was  made,  is  represented  by  a  continuous  line ;  the  value  of 
the   second    five   minutes,  on  the   days   when  a   pause  was 


100 

i~ 

99 

i 

98 

I 

97 

\ 

96 

\ 

95 

\ 

i 

1 

94 

\ 

/ 

1 
1 

I 
1 

93 

V» 

/ 

1 

1 

9? 

N 

1 
1 

91 

1 

90 

1 

/ 

89 

^ 

/ 

88 

If 

1 

J 

r 

87 

1/ 

\  1 

7 

\ 

86 

/ 

\ 

85 

/ 

84 

r- 

83 

1     23456709    10 

Fig.  I.  Calculation  tests  in  Dementia  Pnecox. 

made,  by  a  broken  line,  while  the  average  work  done  in  the 
fir.st  minute  is.  put  down  at  a  hundred.  We  recognize  in 
the  first  place  that  the  values  in  the  first  part  of  the  experi- 
ment sink  very  much  more  quickly  than  in  the  directly 
comparable  normal  attempts,  a  behaviour,  that  may  be 
caused  either  by  specially  great  liability  to  fatigue  or 
through  very  rapid  yielding  of  the  original  will-tension. 
The  striking  oscillations  of  the  values  of  the  average 
minutes  particularly  in  the  second  part  of  the  curve  as  also 
the  high  values  attained  even  here  in  single  minutes  (sixth 


PSYCHIC  SYMPTOMS  25 

and  tenth)  is  in  some  measure  contrary  to  the  assumption 
of  unusually  great  effect  of  fatigue.  It  is  still  more  decidedly 
disproved  by  the  insignificance  of  the  general  effect  of  the 
pause  which  we  know  may  be  regarded  within  certain  limits 
as  the  measure  of  fatigue.  The  work  performed  rises 
considerably,  it  is  true,  in  the  sixth  minute  on  the  days 
when  there  was  a  pause,  but  sinks  again  immediately  and 
keeps  after  that  within  the  limits  of  the  values  reached  on 
the  days  when  there  was  no  pause.  Comparison  with  the 
curves  of  normal  persons  and  still  more  with  those  of  the 
very  easily  fatigued  alcoholics  shows  quite  distinctly  the 
difference  in  the  effect  of  the  pause.  The  even  and  rapid 
fall  of  the  values  in  the  first  beginning  of  the  task,  as  well 
as  immediately  after  the  pause,  points  here  also  to  a  very 
rapid  yielding  of  will-tension,  as  in  alcoholics,  but  it  is  not 
connected  with  heightened  liability  to  fatigue,  but  with  the 
•direct  and  very  considerable  oscillations  of  the  work  done, 
which  clearly  correspond  accurately  to  the  oscillations  of 
attention  observed  by  Busch  and  Grcgor  which  also  usually 
appear  in  the  clinical  picture. 

Judgment. — Further  the  faculty  of  judgment  in  the 
patient  suffers  without  exception  severe  injury.  What 
always  surprises  the  observer  anew  is  the  quiet  complacency 
with  which  the  most  nonsensical  ideas  can  be  uttered  by 
them  and  the  most  incomprehensible  actions  carried  out. 
It  is  true  that  they  often  -move  with  tolerable  certainty  in 
accustomed  paths,  but  in  t-he  psychic  elaboration  of  new 
experiences,  in  the  judgment  of  circumstances  not  hitherto 
experienced,  and  in  particular  of  their  own  state,  in  the 
drawing  of  obvious  conclusions,  in  the  bringing  forward  and 
trial  of  objections,  they  not  infrequently  commit  the  grossest 
blunders.  One  has  the  impression  that  the  patients  are 
not  in  a  position  to  accomplish  that  mental  grouping  of 
ideas  which  is  requisite  for  their  survey  and  comparison, 
their  subordination  among  one  another  and  for  the  discovery 
of  contradictions.  In  this  respect  they  resemble  dreamers 
in  whom  likewise  the  ability  to  sift  the  ideas  which  come 
into  the  mind,  to  arrange  them  and  to  correct  them  accord- 
ing to  the  standards  gained  by  former  experiences  and 
general  ideas  is  abolished.  These  disorders,  on  whose  great 
fundamental  significance  Bleuler  also  lays  most  emphatic 
stress,  suggest  an  encroachment  on  the  inner  action  of  will. 

The  patients  often  have  a  distinct  feeling  of  the  profound 
change  which  has  taken  place  in  them.  They  complain 
that  they  are  "dark  in  the  head,"  not  free,  often  in  confusion, 
no    longer    clear,   and    that    they   have    "  cloud    thoughts." 


26  DEMENTIA  PRECOX 

They  cannot  grasp  a  thought,  cannot  understand  anything ; 
their  mind  is  scattered  ;  their  thoughts  have  flowed  away  ; 
their  brain  is  no  longer  competent,  is  enfeebled.  "  My 
thoughts  went  away  and  will  never  come  back,"  said  a 
patient.  "  My  mind  has  been  taken  away  by  spiritual 
influence  of  speech  and  will."  "  My  whole  mental  power 
has  disappeared,  1  have  sunk  intellectually  below  the  level 
of  a  beast,"  "  I  am  quite  out  of  my  mind,"  "  I  am  being 
punished  a  little  by  my  imagination,"  "  I  have  become  very 
stupid  lately,"  "  I've  got  something  in  my  head,"  "  My  mind 
sometimes  goes  away,"  "The  stupid  fellow  is  confused,"  are 
similar  expressions.  Others  call  themselves  "Half-fools" 
"easily  weak-minded,"  "idiotic";  they  are  afraid  they  are 
going  out  of  their  mind,  becoming  insane,  falling  ill  of 
softening  of  the  brain.  "  Things  go  round  about  inside  ine, 
thoughts  which  belong  to  a  sanatorium,"  said  a  patient. 
Another  said  that  he  had  lost  the  faculty  of  perception  and 
energy,  that  he  was  wholly  changed.  A  patient  declared 
she  was  quite  well,  but  stupid,  and  would  like  to  be  cured, 
while  another  begged  that  she  might  be  freed  from  spirits, 
she  did  not  wish  to  be  mad,  to  be  the  plaything  of  other 
people,  but  wished  to  be  like  other  human  beings,  she  couldn't 
stand  it  any  longer,  she  was  quite  incurable.  Many  patients 
begin  to  read  medical  books,  connect  their  complaint  with 
onanism,  begin  all  sorts  of  cures.  A  patient  was  absorbed 
in  the  books  ;  "  How  Can  I  Become  Energetic  ?"  and  "  Guide 
to  an  Imposing  Appearance,"  and  he  diligently  carried  on 
medical  gymnastics,  deliberately  gazing  at  the  sun  as  long 
as  possible  every  day  in  order  by  so  doing  to  improve  his 
health.  In  contrast  to  these  indications  which  sometimes 
characterize  the  situation  with  surprising  clearness,  under- 
standing of  the  disease  disappears  fairly  rapidly  as  the 
alady  progresses  in  an  overwhelming  majority  of  cases 
even  where  in  the  beginning  it  was  more  or  less  clearly 
present. 

Delusions,  ^either  transitory  or  permanent,  are  developed 
with  extraordinary  frequency  on  the  foundation  of  the  morbid 
change  which  is  created  by  dementia  praecox.  In  the  first 
period  of  the  disease  they  are  usually  by  preference  of  a  sad 
character,  hypochondriacal,  or  ideas  of  sin  or  of  persecution.-^ 
TRe  feetmg  of  disease  takes  on  insane  forms ;  the  brain  is 
burned,  shrunken,  as  if  completely  gone  to  jelly,  full  of  water, 
the  mind  is  "  drawn  like  rags  from  the  brain  " ;  the  patient 
"  has  only  a  little  knuckle  of  brain  left " ;  the  nerves  are 
teased  out.  The  tongue  is  made  of  iron,  the  lungs  are  dried 
up,  blood  is  in  the  spinal  marrow,  wax  in  the  body,  the  heart 


PSYCHIC  SYMPTOMS  27 

is  dried  up,  the  flesh  is  loosened  from  the  bones,  the  blood 
vessels  tremble,  threaten  to  fall  down,  the  spinal  marrow  runs 
out  by  the  genitals.  The  patient  is  not  a  human  being  any 
longer,  he  has  not  got  his  life  any  more,  carries  a  death  skull 
in  his  head,  gets  a  rogue's  skull,  clown's  wrinkles.  Not 
infrequently  these  bodily  changes  are  traced  to  interference 
from  outside.  The  patient  is  "  cut  to  pieces  inside," 
"  vivi.sected,"  his  soul  is  torn  out  of  him,  his  brain  is  blown 
out,  his  heart  is  torn  out  by  poison,  the  physicians  have 
stolen  his  brain  at  an  operation,  and  looked  into  his  inside, 
they  change  his  figure,  his  legs,  his  genitals,  and  eyes,  tear" 
out  his  intestines.  "  Something  else  is  made  of  my  hands 
every  day,"  said  a  patient. 

Ideas  of  Sin. — These  delusions  are  frequently  accom- 
panied by  ideas  of  sin.  The  patient  has  by  a  sinful  life 
destroyed  his  health  of  body  and  mind,  he  is  a  wicked  fellow, 
the  greatest  sinner,  has  confessed  unworthily,  has  committed 
lese-majesty,  has  denied  God,  scorned  the  Holy  Ghost, 
neglected  his  gifts.  The  devil  dwells  in  him,  will  fetch  him, 
God  has  forsaken  him,  he  is  eternally  lost,  he  has  been 
driven  out  of  the  church,  is  going  to  hell.  A  patient  felt  "  as 
if  the  devil  wished  to  take  hold  of  him."  He  is  brought  into 
relation  with  a  murder,  he  is  considered  a  spy,  he  is  under 
police  control,  is  watched  by  detectives,  he  must  appear  in 
court,  must  be  the  scapegoat  for  others,  is  to  be  driven  to 
death.  Many  patients  abuse  and  revile  themselves  in 
connection  with  such  ideas.  A  patient  expressed  himself  as 
follows : — 

"  O  you  filthy  beast,  you  are  lying  down  again  on  an  honoured  bed — 
you  are  again  to  blame  for  it — there  is  a  new  waitress  there  again, 
nothing  but  princesses,  whom  you  are  bringing  into  confusion.  If  you 
only  had  the  courage  to  get  drunk  I  Insolent  beast  I  Thunder  and 
lightning  shall  strike  in  I  If  I  had  defended  myself  better  yesterday. 
The  thunderstorm  shall  strike  in  and  damn  you,  beast — everyone's  falling 
ill  I     1  should  long  ago  have  been  drunk  !  " 

Ideas  of  Persecution. — In  connection  with  these  ideas  of 
sin  ideas  of  persecution  are  invariably  developed,  in  the 
shaping  of  which  hallucinations  of  hearing  generally  play  an 
important  part.  The  patient  notices  that  he  is  looked  at  in  a 
peculiar  way,  laughed  at,  scoffed  at,  that  people  are  jeering  at 
him,  are  spitting  in  front  of  him.  the  clergyman  makes 
allusions  to  him  in  the  sermon.  He  is  grossly  abused  and 
threatened,  his  thoughts  are  influenced,  he  is  surrounded  by  a 
"  spiteful  revolution."  People  spy  on  liim  ;  Jews,  anarchists, 
spiritualists,  persecute  him,  poison  the  atmosphere  with 
poisonous  powder,  the  beer  with  prussic  acid,  generate  magic 
vapours   and  foul    air,  do  not  let   him    take   a  single   good 


28 


DEMENTIA  PRECOX 


breath,  try  to  wash  liim  away  with  musk  water.  He  must 
die,  will  be  shot,  beheaded,  poisoned  by  the  State,  petroleum 
is  poured  over  him  and  set  on  fire,  he  comes  into  the  iron 
maiden,  into  a  vault  with  toads  and  broken  glass.  His  house 
is  blown  into  the  air.  his  wife  is  imprisoned,  his  brother  has  his 
*'  flesh  torn  o(T."  his  family  is  shot ;  the  patient  must  drink 
the  blood  of  his  relatives.  The  peculiar  sensations  of 
influence   lead    to  the  idea  that  witchcraft  and  charms   are 


Representation  of  bodily  influences. 


being  practised.  The  patient  feels  himself  hypnotized  by  a 
magnet,  bewitched,  "  possessed  by  the  god  IMuto,"  surrounded 
by  spirits.  "  A  nest  of  spirits  lives  in  my  brain."  He  has 
been  taken  for  a  telephone  post,  the  telephone  goes  through 
him. 

Ideas  of   Influence. — From   the  examples   which   have 
already    been    given    it    can    be   seen    that    very   often    the 


PSYCHIC  SYMPTOMS  29 

delusion  of  influence  through  external  agents  is  developed  ; 
"  In  a  natural  body  such  things  do  not  happen."  A  patient 
sketched  the  picture  reproduced  iii  Fig.  2,  from  which  at 
least  so  much  can  be  gathered  that  in  his  opinion  his  per- 
secutors took  the  most  varied  parts  of  his  body  as  the  points 
of  attack  for  their  malevolent  importunity.  Many  patients 
are  entangled  in  an  inextricable  net  of  the  most  painful 
ideas  by  the  feeling  of  forced  and  powerless  dependence  on 
strange  influences.  The  following  fragment  of  a  letter  gives 
some  insight  into  that  kind  of  train  of  ideas  : — 

"  I  am  in  terrible  anxiety.  There  is  the  greatest  danger  that  my  life 
is  coming  to  an  end  with  fear,  because  the  whole  institution  is  arranged 
like  clock-work,  which  is  managed,  not  by  reason,  but  by  crazy  heads  in 
the  cells,  which  are  regulated  like  toothed  wheels,  and  not  only  are  the 
cells  so  arranged  that  one  must  move  to  and  fro  in  haranguations  as  on 
a  telegraphic  cobweb  of  nerves,  also  in  the  passages  each  square  yard  is 
a  division  that  demands  a  hanging  man  to  appear  from  anywhere 
whether  it  is  for  a  view  or  a  brutal  person.  At  the  same  time  vapours, 
waves  of  heat  are  developed  in  the  divisions  which  produce  a  dreadful 
degree  of  embarrassment  on  the  one  hand,  brutal  fascinating  power  and 
rapidity  on  the  other  ;  with  that  there  is  a  continuous  sound  of  medium 
sounds,  mediation  voices  which  in  a  cruel  manner  perterrorize  the  mind 
with  contradictions.  It  is  quite  indescribable  with  what  wicked  refinement 
these  dialogues  are  carried  on,  which  by  the  aid  of  influences  are  trans- 
ferred in  destructive  manner  treacherously  from  body  to  body  and  give 
witness  that  so-called  crazy  stationary  in  combination  with  all  sorts  of 
drivers  and  haranguers  are  the  most  cruel  criminals  in  life  which  there 
are,  who  are  yet  surpassed  only  by  another  class  which  in  certain 
circumstances  take  hold  of  one  and  crush  him  with  poisoned  fingers  in 
an  unscrupulous  way  like  a  stuffed  lifeless  mass  in  another  condition.  .  .  '' 

Hxalted  Ideas. — In  a  large  number  of  cases  ideas  of 
exaltation  are  added  to  the  ideas  of  persecution,  sometimes 
from  the  beginning,  more  frequently  first  in  the  further  course 
when  they  often  come  quite  into  the  foreground  of  the 
clinical  picture.  Here  and  there  perhaps  only  ideas  of 
exaltation  are  observed.  The  patient  is  "  something  better," 
born  to  a  higher  place,  the  "  glory  of  Israel,"'  an  inventor,  a 
great  singer,  can  do  what  he  will.  He  is  noble,  of  royal 
blood,  an  officer  of  dragoons,  heir  to  the  throne  of  Bulgaria  ; 
Wilhelm  Rex,  the  Kaiser's  son,  the  greatest  man  in  Germany, 
more  than  King  or  Kaiser.  Or  he  is  the  chosen  one,  the 
prophet,  influenced  by  the  Holy  Ghost,  guardian  angel, 
second  Messiah,  Saviour  of  the  world,  the  little  God,  who  dis- 
tributes grace  and  love,  more  than  the  Holy  Ghost,  the 
Almighty.  He  has  carried  on  the  battle  of  life,  conquered 
death,  turned  the  axis  of  the  earth,  can  make  weather,  can 
walk  on  the  waves.  He  lives  in  Berlin,  gets  a  uniform,  must 
go  to  the  Kaiser,  can  become  minister  and  pope,  will  be  a 
good  match,  will  get  a  great  inheritance,  gets  milliards  from 


30  DEMENTIA  PRECOX 

God  ;  at  the  vvar-oflfice  there  is  gold  deposited  for  him. 
Female  patients  are  countesses,  princesses,  queens  ;  they 
possess  the  whole  world,  have  the  dignity  of  the  Mother  of 
God,  get  gold-embroidered  clothes,  children  from  the  Grand 
Duke  and  from  the  Kaiser,  will  marry  the  surgeon-major  or  a 
prince,  their  uncle  has  left  millions. 

Sexual  Ideas. — A  conspicuously  large  place  in  the 
clinical  picture  of  dementia  prjecox,  seems  to  me  to  be 
occupied  by  sexual  delusions  which  are  often  connected  witli 
the  sexual  sensations  described  above.  The  ideas  of  sin  are  not 
infrequently  connected  with  this  domain.  The  patient  has 
committed  sin  with  his  stepdaughter,  with  his  sister,  has  had 
intercourse  with  cows  so  that  hybrids  have  been  produced  ; 
he  has  committed  a  crime  against  decency,  has  ruined  himself 
by  sexual  excess,  is  homo-sexual,  is  a  sadist.  He  has 
become  impotent  through  onanism,  the  '  neurosis '  proceeds 
from  onanism,  onanism  can  be  recognised  in  his  face.  A 
patient  kept  a  record  of  his  seminal  emissions.  Another 
was  always  obliged  to  think  of  filthiness  (sexual  intercourse 
with  his  mother);  a  third  "could  not  get  rid  of  the  thought 
that  his  wife  committed  lewdness  with  animals  in  order  to 
punish  him  for  onanism."  Improper  thoughts  always  came 
to  a  patient  against  her  will.  Female  patients  notice  that 
men  wish  to  seduce  them,  policemen  and  soldiers  wish  to 
have  them  all.  A  dog  with  a  muzzle  on  seemed  to  a  patient 
to  indicate  his  sexual  restraint  ;  when  his  landlady  brought 
him  an  egg  for  breakfast  he  regarded  that  as  an  invitation  to 
sexual  intercourse  and  prepared  to  accept  it.  Another  patient 
felt  impelled  to  have  intercourse  with  his  sister. 

Rut  above  all  things  patients  feel  themselves  sexually 
influenced  in  the  most  varied  ways.  A  neighbour's  wife 
occupied  herself  at  night  with  the  genitals  of  the  patient,  nuns 
constantly  withdraw  seminal  emissions  from  him  and  behave 
immodestly  before  him.  '  Love-stories  '  are  given  him  in  his 
coffee,  grated  flesh-flies  are  mixed  in  his  food  so  that  his  penis 
becomes  bine.  Sexual  dreams  are  suggested  to  him,  proposals 
are  made  to  him  from  a  distance,  women  with  butterfly  wings 
come  to  live  with  him,  the  landlady  "will  force  nature  on 
him."  He  is  weakened  in  the  genitals,  loses  sexual  power, 
something  is  stuck  in  from  without,  he  is  enticed  to  onanism, 
he  is  castrated  because  of  self-abuse,  the  .students  want  to 
"  dock "  him.  Women  feel  that  they  have  lost  their 
virtue,  that  their  honour  has  been  tarnished  ;  their  father, 
their  clergyman  has  abused  them  ;  their  master,  the  Kaiser 
comes  at  night  to  them.  Gentlemen  are  sent  to  them  for 
sexual  intercourse,  someone  lies  on  them  every  night.     They 


PSYCHIC  SYMPTOMS  31 

are  raped  in  aniESthesia,  "  spiritually  abused,"  are  pregnant  by 
a  cup  of  coffee,  by  a  shadow,  by  the  devil,  by  Lohengrin,  have 
children  in  their  body,  must  always  bring  forth  ;  things  are 
said  as  if  they  were  expecting  to  be  confined  and  were 
committing  abortion  ;  their  womb  rises  into  their  head.  The 
institution  is  a  brothel,  a  house  of  ill-lame,  in  which  filthiness 
is  carried  on. 

In  connection  with  these  insane  ideas  an  irritable  aversion 
to  the  other  sex  is  not  infrequently  developed.  A  patient 
spat  at  the  girls  he  met.  Women  fall  into  lively  excitement 
as  soon  as  the  physician  comes  near,  speak  abusively  in 
obscene  language  about  debauchery  and  whoredom,  will  not 
have  anything  to  do  with  men.  A  patient  cut  off  her  hair  in 
order  to  displease  her  followers. 

Ideas  of  Reference. — The  events  of  the  outside  world 
are  brought  into  manifold  connection  with  the  delusions 
by  means  of  "conjecturing  thoughts."  Indifferent  remarks 
and  chance  looks,  the  whispering  of  other  people,  appear 
suspicious  to  the  patient.  "  I  feel  myself  referred  to  there," 
said  a  patient.  A  passer-by  shows  off  his  big  nose,  his  red 
face  on  purpo.se  to  mock  at  the  patient.  News  in  the  papers 
contain  allusions,  he  finds  in  them  thoughts  which  he  has  had. 
"  My  instinct  tells  me  that,"  asserted  a  patient.  His  fellow- 
patients  are  appointed  to  watch  him  ;  a  patient  who  heard 
others  speaking  about  him  said,  "  I  think  to  myself  that  the 
doctor  gives  people  the  commission  to  make  me  mad,  the 
thunderstorm  must  help  too."  On  the  street  he  meets  girls 
with  whom  he  formerly  had  intercourse  ;  the  tramway  gives 
signs  with  the  bell  ;  the  sentries  present  arms.  A  patient 
recognised  by  the  finger  nails  of  his  superior  that  he  was  his 
brother.  People  are  astonishingly  friendly;  it  is  all  a  farce  ; 
there  is  a  change  in  his  military  pass.  A  patient  thought  it 
better  to  go  from  home  when  a  gas  pipe  was  going  to  be 
repaired  in  his  house.  Another  read  from  the  clothes  of  the 
physicians  their  thoughts  about  him  ;  a  star  in  the  sky  pointed 
out  his  grave  to  a  third  ;  the  fern  in  his  buttonhole  indicated 
war  to  a  fourth  ;  all  labels  and  buttons  that  he  found  were 
important  papers  and  pieces  of  money  to  a  fifth.  A  patient 
held  the  opinion  that  misfortunes  were  brought  into  connec- 
tion with  her  menses  and  she  would  be  called  to  account  for 
it.  Frequently  the  delusions  are  connected  with  dreams 
which  are  regarded  simply  as  actual  experiences  or  as 
significant  portents. 

The  delusions  of  our  patients  often  show,  as  the  given 
examples  do,  an  extraordinary,  sometimes  wholly  nonsensical 
stamp.    As  a  rule  also  they  are  either  not  at  all,  or  only  in  a  very 


32  DEMENTIA   PR^ECOX 

sui^erficial  way,  worked  up  mentally  and  are  scarcely  brought 
into  inner  connection  with  one  another.  The  patients  do  not 
try  to  give  any  account  of  the  reliability  of  their  observations 
and  conclusions,  do  not  search  for  explanations  of  their 
remarkable  experiences,  their  persecutions,  their  good  fortune  ; 
they  make  no  difficulties  and  pay  no  regard  if  any  are  pointed 
out  to  them,  but  rather  hold  the  more  to  their  insane  ideas 
without  further  proof.  "  I  have  innumerable  proofs  and  not 
one,"  said  a  patient." 

But  always  here  and  there  we  meet  with  a  certain 
systematisation  of  the  morbid  ideas  mostly  indeed  only 
temporary ;  they  are  connected  with  one  another  by  all  sorts 
of  unwarranted  assumptions  or  subtle  arguments.  For 
example  a  patient  wholly  out  of  his  mind  demanded  as  com- 
pensation for  his  supposed  unjust  detainment  in  the 
institution  simply  the  civil  list  of  the  King,  as  he  explained 
that  the  denial  of  justice,  if  only  towards  a  single  subject, 
.  signified  the  virtual  abdication  of  the  King  as  the  stronghold 
of  justice  ;  he,  the  injured  party,  must  accordingly  demand 
what  the  King  by  the  permission  of  injustice  voluntarily 
resigned. 

In  accordance  with  their  generally  very  loose  inner  con- 
nection the  delusions  are  for  the  most  part  by  no  means 
constant,  but  they  change  their  content  more  or  less  quickly 
by  the  disappearance  of  former  and  the  addition  of  new  con- 
stituents. At  times  the  patients  produce  nearly  every  day 
new  delusional  details  in  spite  of  certain  persistently  returning 
characteristic  featuies,  and  perhaps  let  themselves  be  stimulated 
to  further  delusions  by  suggestion.  In  the  overwhelming 
majority  of  cases,  however,  the  delusions  which  are  at 
first  often  very  luxuriant,  gradually  cease.  At  most  a  few 
insane  ideas  are  for  some  time  adhered  to  without  being 
further  developed,  or  they  appear  once  again  from  time  to 
time,  or  finally  they  fall  into  oblivion  permanently  and 
completely.  Only  in  that  group  of  observations  with  which 
we  shall  later  become  acquainted  as  paranoid  dementia  are 
the  delusional  ideas  generally  more  connected  for  a  longer  time, 
perhaps  for  some  years,  and  appear  unchanged  in  the  main 
point,  but  here  also  they  become  gradually  more  confused  and 
more  contradictory. 

Emotion. — Very  striking  and  profound  damage  occurs  as 
a  rule  in  the  emotional  life  of  our  patients.  The  most 
important  of  these  changes  is  their  emotional  dulness.  The 
disorders  of  attention  which  have  already  been  mentioned 
might  be  essentially  connected  with  the  loss  of  interest,  the 
loss    of    inner    sympathy,    with    the    giving   way    of   those 


PSYCHIC  SYMPTOMS  33 

emotional  main-springs  which  move  us  to  exert  our  mental 
powers,  to  accomplish  our  tasks,  to  follow  trains  of  thought. 
JHhp*  «siilgular  indifferencg^pf  jy}e_p^atients  tm^^  their  former 
emotional  relations,  the  .:ejctinctio7r"or^ffection  for  relatives 
ancnVfewfer'isr^satisfaction  intlieir  work  and  vocatt^g^lSr 
re*c?(eatlort  and~pleamires,  Is  iToT  seldom  the^Rrst  and  most 
strikfrrg  symptom  of  the  onset  of  disease,  j  The  patients  have 
no  real  joy  in  life,  " no  human  feelings";  to  them  "nothing 
matters,  everything  is  the  same  ";  they  feel  "no  griefand  no 
joy,"  "  their  heart  is  not  in  what  they  say,"  A  patient  saidTie 
was  childish  and  without  interest,  as  he  had  never  been  before. 
Another  said  that  nothing  gave  him  pleasure,  he  was  sad  and 
yet  not  sad.  Again  another  stated  that  he  had  "  inward  peace 
in  his  soul  ";  a  fourth  said  "  I  am  as  cold  as  it  is  possible  to  be." 
"  Everything  is  frightfully  indifferent  to  me,  even  if  I  should 
become  quite  insane,"  said  a  female  patient. 

Hopes  and  wishes,  cares  and  anxieties  are  silent ;  the 
patient  accepts  without  emotion  dismissal  from  his  post, 
being  brought  to  the  institution,  sinking  to  the  life  of  a 
vagrant,  the  management  of  his  own  affairs  being  taken  from 
him  ;  he  remains  without  more  ado  where  he  is  put  "  till 
he  is  dismissed,"  begs  that  he  may  be  taken  care  of  in  an 
institution,  feels  no  humiliation,  no  satisfaction  ;  he  lives  one 
day  at  a  time  in  a  state  of  apathy.  The  background  of  his 
disposition  is  either  a  meaningless  hilarity  or  a  morose  and 
shy  irritability.  One  of  the  most  _^hrirf^rferistir  features  of 
the  disease  is  a  frequent,  causeles^^^^udden  outburst  of 
laughtet%\.\\di\.  often  is  strikingly  in  evidence  already  at  the" 
very  commencement.  "  His  thoughts  always  made  him 
laugh,"  said  the  relatives  of  a  patient. 

Moral  sentiments  also  and  their  regulating  influence  on 
action  suffer  severe  loss.  \  Not  only  in  the  former  history  of 
the  patient  do  we  find  manifold  contraventions  of  the  penal 
code  and  public  order,  but  also  during  the  disease  itself  deeds 
are  frequently  committed  which  are  dangerous  to  the  common 
weal./  Pighini  found  that  among  114  mental  patients  who 
were  sentenced,  49*  i  per  cent,  were  cases  of  dementia  praecox. 

Loss  of  sympathy  is  shown  in  indifference  and  want  of 
understanding  for  the  misfortunes  of  others,  in  the  roughness 
with  which  the  patients  occasionally  ill-use  tl^!F~LuMrpdii'tDns 
iTT  lllibfui  tune  'Uil  the  most  tntiing  occasion  ;  a  woman  tried 
to  strangle  the  patient  in  the  next  bed  in  order  to  free  her 
from  her  troubles.  Even  the  fate  of  his  nearest  relatives  affect 
the  patient  little  or  not  at  all.  He  receives  their  visits  without 
a  greeting  or  other  sign  of  emotion,  does  not  enquire  how 
they  are,  takes  no  share  in  their  joys  or  sorrows.     A  patient 

c 


34  DEMENTIA  PR^-XOX 

remained   quite   indiflfereiit  to  the  death  of  his  mother,  and 
then  excused  himself,  as  lie  could  not  help  it  ;  "  Life  is  nothing 
to  me  and  death  is  nothing,"  he  said.     A   patient  who  had 
Jk^     ^ut   the   throats   of  her   three   children    because   they   were 
ft       /oewitched    and   would    not    be  rightly  brought    up,  did    not 
'  \    /  show  afterwards   the   slightest   emotion  ;    her   children  were 
I    /    now  angels  and  well  taken  care  of,  she  explained, 
\  /  Another    phenomenon    of    emotional    dementia    is    the 

1/        disappearance  of  delicacy  of  feeling.     The   patients  have  no 
r  longer  any  regard  for  their  surroundings;   they  do  not  suit 

their  behaviour  to  the  situation  in  which  they  are,  they  conduct 
themselves  in  a  free  and  easy  way,  laugh  on  .'•erious  occasions, 
are  rude  and  impertinent  towards  their  superiors,  challenge 
them  to  duels,  lose  their  deportment  and  personal  dignity; 
they  go  about  in  untidy  and  dirty  clothes,  unwashed, 
unkempt,  go  with  a  lighted  cigar  into  church,  speak  familiarly 
to  strangers,  decorate  themselves  with  gay  ribbons.  The 
feeling  of  disgust  and  of  shame  is  also  lost.  The  patients 
do  not  preserve  control  of  the  sphincters.  They  pass  their 
excreta  under  them,  they  ease  themselves  under  the  bed, 
in  the  spitoon,  in  their  hat,  in  the  dishes,  they  make  little 
balls  of  faeces,  collect  their  evacuations  in  handkerchiefs  or 
cigar-boxes,  smear  themselves  with  urine,  wash  their  hand- 
kerchief in  the  full  chamber;  they  take  their  food  with  their 
fingers,  they  spit  in  their  bed  or  in  their  hand,  or  on  their 
bread,  they  devour  beetles  and  worms,  sip  dirty  bath-water,  or 
empty  at  one  draught  the  full  spittoon.  The  want  of  a  feeling 
of  shame  expresses  itself  in  regardless  uncovering  of  their 
persons,  in  making  sexual  experiences  public,  in  obscene  talk, 
in  improper  advances,  and  in  shameless  masturbation. 

It  appears  also  that  the  patients  often  become  less  sensitive 
to  bodily  discomfort ;  they  endure  uncomfortable  positions, 
pricks  of  a  needle,  injuries,  without  thinking  much  about 
it;  burn  themselves  with  their  cigar,  hurt  themselves,  tear 
out  .the  hair  from  their  genitals,  let  the  glaring  noonday 
sun  shine  in  their  face  for  hours,  do  not  chase  away  the  flies 
which  settle  on  their  eyelids.  Often,  however,  food  retains 
for  a  long  time  a  special  power  of  attraction.  When  their 
relatives  visit  them  the  patients  are  seen  hurriedly  rummaging 
through  their  bags  and  baskets  for  things  to  eat,  which  they 
immediately  devour  to  the  last  crumb,  chewing  with  their 
mouths  full.  In  the  terminal  conditions  of  the  illness,  perfect 
indifference  towards  all  that  goes  on  in  the  neighbourhood 
is  often  enough  one  of  the  principal  features  of  the  clinical 
picture. 

On  the  foundation  of  the  more  or  less  strongly  marked 


PSYCHIC  SYMPTOMS  35 

emotional  dulness,  however,  sudden  oscillations  of  emotional 
equilibrimn  of  extraordinary  violence  may  be  developed.  In 
particular,  sudden  outbursts  of  rage  with  or  without  external 
occasion  are  not  infrequent  and  can  lead  to  most  serious 
deeds  of  violence.  The  patients  destroy  objects,  smash 
windows,  force  open  doors,  deal  out  boxes  on  the  ear.  A 
patient  stabbed  a  girl's  arm,  another  killed  his  master,  a  third 
killed  a  companion  by  whom  he  felt  himself  influenced.  On 
the  other  hand  the  patients  may  suddenly  fall  into  the  most 
unrestrained  merriment  with  uncontrollable  laughter,  seldomer 
into  states  of  intense  anguish.  All  these  emotions  are  dis- 
tinguished by  the  suddenness  of  their  onset  and  disappearance 
and  the  often  quite  sudden  change  of  mood.  At  the  same 
time  they  have  often  no  recognisable  connection  with  the 
experiences  or  the  ideas  of  the  patients.  Bleuler,  however, 
brings  forward  the  view  that  in  such  states  it  is  usually  a 
case  of  contact  with  the  "  complexes,"  the  sensitive  traumata 
of  life.  I  have  not  been  able  to  convince  myself  of  that,  but 
believe  much  rather  that  we  have  essentially  to  do  with  the 
loss  of  that  permanent  colouring  of  the  background  of  mood 
which  in  normal  people  influences  all  chance  oscillations  of 
the  emotions,  equalising  and  checking  them  and  which  only 
then  lets  them  appear  in  greater  strength  when  an  important 
occasion  finds  a  powerful  echo  in  our  being. 

Stransky  has,  therefore,  not  without  justification,  said  that 
it  is  a  case  in  our  patients  less  of  an  emotional  devastation, 
than  of  an  "ataxia  of  the  feelings^'  a  loss  of  connection  with 
other  mental  occurrences.  I  am  inclined  to  assume  that 
this  confusion  in  the  emotional  life  is  caused  essentially  by 
the  weakening  of  the  higher  permanent  feelings,  whose  task 
it  is  on  the  one  hand  to  check  sudden  oscillations  of  feeling, 
on  the  other  hand  to  give  to  our  inward  states  permanently 
equable  tension  and  temperature,  and  so  to  become  security 
for  the  agreement  of  our  emotional  relations  with  the  outer 
world.  Exactly  in  the  terminal  conditions  with  pronounced 
dementia  one  frequently  observes  emotional  irritability  with 
sudden,  violent  outbursts,  and  also  excitement  which  appears 
without  cause  with  more  or  less  regular  periodicity. 

The  comparatively  great  independence  on  outer  influences 
of  the  temper  has  as  a  consequence  that  it  often  remains 
for  a  very  long  time  extremely  uniform.  Many  patients 
constantly  exhibit  a  silly  cheerfulness,  others  always  a 
lachrymose  dull  depression  or  ap  ill-humoured  strained 
behaviour.  They  are  not  brought  out  of  their  careless 
contentment  either  by  unpleasant  occurrences  or  by  the  blows 
of  fate,  nor  can  they  be  comforted,  nor  can  their  affection  be 


36  DEMENTIA  PRECOX 

won.  But  the  course  of  the  illness  itself  can  bring  about 
unexpectedly  some  day  a  sudden  change  in  their  mood. 

Here  and  there  it  may  be  observed  that  the  disposition  of 
the  patients  is  exactly  contrary  to  the  actual  state  of  affairs. 
The  patients  laugh  while  they  narrate  an  attempt  at  suicide, 
or  the  death  of  a  near  relative,  and  weep  bitterly  on  any 
occasion  for  mirth.  Sometimes  it  is  only  a  case  of  want  of 
relationship  between  mood  and  expression — of  paramimia. 
The  most  frequent  occurrence  of  the  kind  is  senseless 
laughing  without  mirthfulness.  The  patient  cannot  help 
laughing  ;  he  does  it  even  when  he  does  not  wish  to  ;  he  has 
"laughing  fever,"  said  a  patient.  Also  the  mingling  of 
crying  and  laughing,  crying  in  tune,  dancing  about  with 
fixed  and  furrowed  features  belong  to  the  paramimic 
phenomena. 

But  further  there  sometimes  takes  'place  in  the  patients  a 
complete  reversal  of  their  emotiofial  relationships,  which  may 
be  the  first  sign  of  the  approaching  illness.  Former  feelings 
of  affection  are  changed  into  downright  aversictn.  In 
especial  the  nearest  relatives  suffer  frequently.  Towards  his 
parents  of  whom  he  has  hitherto  been  fond,  the  patient 
behaves  rudely,  haughtily,  threateningly ;  he  abuses  them  in 
obscene  language ;  his  mother  is  an  old  spitfire,  his  father  is 
a  rogue,  a  perjured  dog.  His  mother  stupefies  him,  is  a 
witch  ;  his  father  causes  him  headache  ;  his  sister  is  the 
devil,  "  the  whore  who  has  ruined  his  life."  His  brother  has 
signed  the  deed  for  his  execution  ;  his  brother-in-law  shoots 
him.  The  former  lover  becomes  an  enemy  and  persecutor, 
who  stirs  up  the  people  and  is  everywhere  in  evidence.  And 
senseless  jealousy  is  not  rare.  His  wife  has  secretly  married 
another  man  ;  the  nurses  wish  to  alienate  the  loved  one ; 
the  husband  has  been  changed.  A  patient  suddenly  tried  to 
poison  her  new-born  child,  as  it  seemed  to  her  it  was  not  the 
right  one  ;  she  asked  the  public  prosecutor  by  telegraph  to 
arrest  her  husband  as  he  wanted  to  murder  her. 

Like  the  thoughts,  the  feelings  of  the  patient  can  also 
occasionally  be  "  transferred "  in  his  opinion  ;  "  there  are 
transferences  of  grief " ;  "  feelings  of  anguish  come  from 
outside  by  the  ears,  inward  thoughts  of  persecution,"  said  a 
patient.  Another  asserted  that  his  sister  had  an  apparatus 
for  speaking  at  a  distance,  150  to  300  miles;  by  the  current 
one  could  be  made  to  fall  in  love,  to  grieve,  to  have  bad 
thoughts.  The  patient  '^  has  no  peace  at  work  because  some 
one  always  sits  beside  him."  "  The  laughing  is  made  by 
voices,"  explained  a  patient ;  "  that  is  not  laughing,  my 
mouth  is  drawn  askew,"  said  another  ;  "  the  nerve  of  laughing 


PSYCHIC  SYMPTOMS  37 

is  irritated,"  said  a  third,  it  is  an  electrical  laughing.  "  The 
laughing  comes  to  me  from  beneath  upwards ;  it  makes  me 
laugh,  and  yet  it  is  not  laughable,"  said  a  fourth  ;  and  a 
patient  complained,  "  Now  again  another  quite  stupid  fit  of 
laughing  is  caused  in  me  ! " 

Volition. — Hand  in  hand  with  the  profound  disorders  of 
the  emotional  life  go  the  extensive  and  varied  morbid 
manifestations  in  the  domain  of  work  and  conduct,  which 
specially  give  the  clinical  picture  its  peculiar  stamp.  They 
are  composed  of  a  series  of  diverse  fundamental  disorders. 
In  the  first  place  we  have  commonly  to  do  with  a  general 
weakening  of  volitional  impulses.  The  patients  have  lost 
every  independent  inclination  for  work  and  action  ;  they  sit 
about  idle,  trouble  themselves  about  nothing,  do  not  go  to 
their  work,  neglect  their  most  pressing  obligations,  although 
they  are  perhaps  still  capable  of  employing  themselves 
in  a  reasonable  way  if  stimulated  from  outside.  They 
experience  no  tediousness,  have  no  need  to  pass  the  time, 
'*  no  more  joy  in  work,"  but  can  lie  in  bed  unoccupied 
for  days  and  weeks,  stand  about  in  corners,  *'  stare  into  a 
hole,"  watch  the  toes  of  their  boots  or  wander  aimlessly 
about.  For  work  they  have  "  no  inclination  " ;  "  their  nerves 
can't  stand  it."  A  patient  did  no  work  for  two  years,  "in 
order  not  to  deprive  people  of  gain  "  ;  another  had  in  view, 
after  having  used  his  last  sovereign,  to  go  into  the  Lake  of 
Constance  ;  a  third  asked  "  for  an  easy  job,  perhaps  as  a 
clergyman." 

Automatic  Obedience.-^This   loss   of  instinct  for  occu-     ^^.j^- 
pation,    even    though    its    clinical    manifestations    may    be     "" 
inconspicuous,  represents  without  doubt  an  unusually  severe       X^ 
disorder,  as  the  activity  of  the  will  forms  the  most  important 
foundation    of  psychic   personality.     To   it   there   stands  in  i 
close   relationship   that  susceptibility  of  the  will  to  in^MenceA 
which  finds  its  most  distmct  expression  in  the  phenomena"©! 
automatic  obedience.     As  the  inner  activity  of  volition  fails, 
the  resistance  which  outside  influences  meet  within  us  is  also 
easily   lost.     The    patients  therefore   are  usually  docile,  let 
themselves    be    driven   as   a   herd,   so   that   they   form   the 
necessary  nucleus  of  those  crowds  which  conform  willingly 
to  the  monotonous  daily  round  in  large  institutions.     A  not 
inconsiderable  number  join  without  resistance  the  crowd  of 
vagabonds    which    chance    leads    to-day    hither,    to-morrow 
thither. 

But  also  fully  developed  automatic  obedience  is  extremeh- 
frequent.  It  is  found  in  all  stages  of  the  disease,  at  the 
beginning  as  well  as  at  the  end,  not  infrequently  also  as  the 


38 


DEMENTIA  PRiECOX 


one  noticeable  remaining  feature  of  the  disease  in  otherwise 
apparently  complete  recovery.  It  is  seen  in  zvaxy  flexibility, 
in  the  preservation  of  whatever  positions  the  patient  may  be 
put  in,  even  although  they  may  be  very  uncomfortable. 
This  very  striking  disorder  is  plainly  seen  in  the  group  in 
Fig.  3,  which  brings  together  a  series  of  patients  suffering  from 
dementia  pr.tcox.  They  were  put  without  difficulty  in  the 
and  kept  them,  some  with  a  sly  laugh, 
seriousness.  The  patient  sitting  on  the 
fairly  demented,  while  the  three  patients 
still  in  the  initial  stages  of  the   disease. 


peculiar  positions 
others  with  rigid 
right  was  already 
on   the   left   were 


* 

H 

m 

^^^^H       .^^^^^^^^^^'~' 1 

Fig.  3.  Group  of  schizophrenic  patients. 

Further  the  Figures  4,  5,  6  show  the  same  patient  in  different 
positions  in  which  he  was  put,  of  which  specially  the  last  one 
could  obviously  be  preserved  only  by  a  considerable  expendi- 
ture of  force.  "  I  have  to  do  it,"  said  a  patient,  when  he  was 
asked  about  the  cause  of  his  cataleptic  behaviour ;  another 
said,  "  It  happens  to  order." 

Again  automatic  obedience,  as  its  name  expresses,  appears 
in  involuntary  obedience  when  called  upon  to  do  things, 
even  those  which  are  visibly  disagreeble  to  the  patient.  He 
continues  to  put  out  his  tongue  when  commanded  to  do  so 


PSYCHIC  SYMPTOMS 


39 


although  one  threatens  to  stab  it,  and  causes  him  pain  with 
a  needle,  as  can  be  seen  by  the  grimaces  he  makes.  It  might 
also  be  considered  as  automatic  obedience  that  the  patient 
submits  to  unpleasant  touching  of  his  face,  tickling  of  the 
mucous  membrane  of  his  nose,  piercing  a  fold  of  his  eyelid 
without  defending  himself,  in  as   far   as   these  proceedings 


Fig.  4.   Waxy  flexibility  (a). 

contain  the  unspoken  command  not  to  prevent  them.  Again 
ccholalia  and  echopraxis  belong  to  this  group  of  phenomena, 
the  involuntary  repetition  of  words  said  to  them,  the  imitation 
of  movements  made  in  front  of  them,  or  the  continuance  of 
movements  passively  initiated.  "  I  do  it  because  you  wish  it 
so."     "  I   place  myself  according   to   what   is   commanded." 


40 


DEMENTIA  PR^^COX 


"  I  was  unconscious,  I  had  to  do  everything,"  say  the  patients. 
But  in  the  end  a  curious  constraint  of  the  movements  is 
invariably  connected  with  automatic  obedience,  whicii 
apparently  stands  in  relation  to  the  inner  want  of  freedom 
of  the  patient,  with  the  uncertainty  of  the  patient's  own  will 
and  its  susceptibility  to  influence  from  all  possible  accidental 
occurrences.     Often  indeed  is  it  so  distinctly  marked  that  it 


Waxy  flexibility  (b). 


makes  the  conclusion  very  probable  that  there  will  be  other 
disorders  of  automatic  obedience. 

Impulsive  actions — The  weakening  of  the  dominion  of 
will  in  the  psychic  life  provides  further,  as  it  apf>ears,  the 
conditions  favourable  for  the  appearance  cf  the  impulsive 
actions   which   attain    such   great   significance   in   dementia 


PSYCHIC  SYMPTOMS 


41 


praecox.  The  relaxing  of  those  restraints,  which  keep  the 
activity  of  normal  people  in  well  defined  paths,  provides 
chance  impulses  with  the  freedom  to  turn  themselves  un- 
hesitatingly into  action  without  regard  to  the  end  in  view  or 
to  suitability.  So  it  happens  that  the  patients  commit  a 
great  many  of  the  most  nonsensical  and  incomprehensible 
acts  of  which  they  themselves  are  usually  unable  to  explain 


Fig.  6.   Waxy  flexibility  (r). 

the  cause.  "  I  have  a  sort  of  feeling  as  if  I  must  do  that," 
explained  a  patient  who  was  screaming  and  biting  everything. 
■"  I  had  no  free  course  left  me,  I  had  often  to  do  things 
without  knowing  why,"  said  another.  A  third  said,  'I  must 
shuffle  and  do  gymnastics,"  a  fourth,  "  I  must  scream  in 
order  not  to  burst "  ;  a  fifth  sang,  "  because  it  was  desired  " ; 


42  DEMENTIA  PRECOX 

a  sixth  asserted  that  "  God  made  him  spit."  The  patients 
suddenly  break  a  mirror  in  pieces,  knock  over  tables  and 
chairs,  take  down  pictures,  throw  objects  out  at  the  window, 
climb  on  to  a  cupboard,  set  fire  to  their  hair,  run  naked  into 
the  street,  ring  bells,  put  their  heads  in  the  basin  of  the 
water-closet,  set  the  chamber  on  their  head,  creep  under  the 
table,  smash  a  lamp.  Usually  such  senseless  actions  are 
carried  out  with  great  violence,  suddenly,  and  with  lightning 
rapidity,  so  that  it  is  impossible  to  prevent  them  ;  the  patients 
also  oppose  themselves  in  the  most  insolent  way  to  every 
attempt  to  keep  them  from  doing  these  things.  "  I  had  a 
feeling  as  though  I  were  not  doing  my  duty  ;  there  was  an 
impulse  in  me,"  were  the  terms  in  which  a  patient  described 
his  inner  perceptions.  Another  smashed  the  fire-alarm, 
"  because  he  had  the  impulse  in  his  arm";  a  third,  who  with 
all  his  might  was  struggling  and  drumming  called  out,  "  I 
cannot  do  it  any  more  vigorously  !  Am  I  to  do  it  still  more 
vigorously?  " 

In  certain  circumstances  the  impulsive  actions  of  the 
patients  may  become  extraordinarily  dangerous.  The 
patients  suddenly  give  a  box  on  the  ear  to  any  one  they 
meet,  make  a  furious  attack  on  a  neighbour,  set  fire  to  beds, 
tear  off  a  gas-bracket.  A  patient  tried  to  throttle  his  uncle's 
grandchild  ;  another  smashed  the  bell  at  a  level-crossing  and 
wanted  to  tear  up  the  rails  as  well  ;  he  alleged  as  his  motive 
that  he  had  been  shut  up  in  Roumania  and  made  insane. 
Others  bite  their  arm,  strike  their  face,  squeeze  their  testicles 
together,  drink  up  any  bottle  of  medicine,  put  beetles  or 
stones  in  their  ears,  make  continuous  attempts  at  suicide, 
suddenly  hang  themselves,  jump  out  at  the  window,  throw 
themselves  in  front  of  the  tramway  ;  a  patient  broke  a  tea- 
spoon in  order  to  stick  it  into  his  neck. 

Often  sexual  impulses  are  also  very  lively.  The  patients 
masturbate  without  regard  for  their  surroundings,  or  in  the 
examination  by  the  physician,  snatch  at  the  genitals  of  their 
fellow-patients,  take  hold  of  their  sister  under  her  skirts.  A 
patient  raped  his  brother's  cook  and  tried  to  do  the  same  to 
his  sister-in-law.  A  female  patient  for  years  made  regardless 
sexual  attacks,  on  the  physicians,  in  order  through  inter- 
course "  to  be  freed  from  the  oppression  on  her  breast." 

Catatonic  Excitement.  —  The  peculiar  condition  of 
catatonic  excitement  consists  of  a  collection  of  .senseless 
actions  and  movements  with  which  we  shall  have  later  to 
occupy  ourselves  more  in  detail.  Besides  impulsive  actions 
we  meet  at  the  same  time  in  large  number  and  variety  with 
discharges    of  will-power,   in    which   every   relation  to  the 


PSYCHIC  SYMPTOMS  43 

realisation  of  fixed  aims  is  wanting,  but  which  appear  in  the 
form  of  completely  aimless  movements.  They  have  no 
connection  either  among  each  other  or  with  ideas  or 
emotions,  but  have  the  tendency  to  repeat  themselves  very 
often  either  in  the  same  form  or  with  all  manner  of  changes. 
Here  and  there  they  still  bear  the  character  of  mutilated 
movements  of  purpose  or  expression,  from  which  partly  at 
least  they  may  arise.  The  patients  hop,  jump,  turn  somer- 
saults, scream,  grunt,  see-saw,  drum,  screech,  go  through  the 
movements  of  ringing,  of  playing  the  violin,  usually  with  the 
expenditure  of  all  their  energy,  but  without  any  recognisable 
aim. 

Stereotypy. — With  the  disorders  of  volition  which  have 
already  been  considered,  there  is  very  frequently  connected 
in  dementia  pra^cox,  as  has  already  been  indicated,  another, 
the  tendency  to  the  instinctive  persistence  of  the  same 
volitional  movements,  stereotypy.  It  shows  itself  in  con- 
tinuance in  the  same  positions  as  well  as  in  the  repetition  of 
the  same  movements  or  actions.  The  will  is  here  to  a  certain 
extent  influenced  for  a  considerable  time  by  previous  activities, 
in  the  same  way  as  in  automatic  obedience.  Stransky  there- 
fore speaks,  probably  with  right,  of  an  "  auto-echolalia  '^  and 
"  auto-echopraxis."  The  patients  stand  or  kneel  for  hours, 
days,  or  still  longer,  on  the  same  spot,  lie  in  the  most  un- 
comfortable positions  in  bed,  fold  their  hands  spasmodically, 
even  till  pressure-sores  appear,  take  up  the  position  of 
fencing.  Usually  it  is  possible  only  with  the  most  extreme 
force  to  bring  them  out  of  such  a  position,  which  they 
usually  take  up  again  as  soon  as  the  hindrance  has  ceased. 

Much  more  varied  are  the  stereotypies  of  movement 
which  we  often  meet  in  the  most  marked  form,  especially  in 
states  of  catatonic  excitement.  In  the  milder  degrees  it  is 
more  a  matter  of  a  certain  uniformity  of  volitional  expression, 
the  persistence  of  definite  activities.  The  patients  always 
make  the  same  gestures,  go  the  same  ways,  pull  their  hair  out 
like  the  patient  represented  in  Fig.  7 ;  they  make  bread 
pellets,  continually  scratch  their  faces,  slide  dovyn  on  their 
knees,  make  peculiar  noises,  make  grimaces,  play  all  day  long, 
the  same  tune  on  the  piano  ;  a  patient  "  threw  his  roll  on  to 
the  table  a  hundred  times."  In  the  same  category  there 
belong  also  twitching  movements  in  different  groups  of 
muscles,  raising  a  shoulder,  "  contortionist  movements," 
waving  with  the  hands,  touching  definite  parts  of  their  bodies 
with  their  fingers,  conspicuous  clearing  of  their  throats, 
smacking  of  their  lips,  snorting.  A  patient  who  always 
twitched  with  his  alae  nasi,  explained,  "  That  is  just  my  way." 


44 


DEMENTIA  PR/ECOX 


Sometimes  the  whole  volitional  expression  of  the  patient 
is  dominated  by  stereotypies  for  a  long  time,  so  that  his 
doings  resolve  themselves  into  an  almost  uninterrupted  series 
of  senseless  movements  which  are  either  monotonous,  or 
repeat  themselves  with  slight  changes.  A  certain  rhythm 
invariably  results.  The  patients  rock  themselves  from  one 
leg  on  to  the  other,  keep  time,  "pull  letters  away  from  their 
fingertips,"  spread  out  their  fingers  with  a  quavering  move- 
ment, clap  their  hands,  shake  their  heads,  bellow  keeping 
time,  give  themselves  boxes  on  their  ears,  run  up  and  down 


Fig  7.     I  lair-pulling  puticiU. 

in  double  quick  time.  About  the  motives  for  these 
proceedings,  no  satisfactorx-  account  is  got  from  them.  A 
patient  who  always  rocked  himself  rhythmically  from  side  to 
side,  simply  e.xplained,  "  It  happens  so  in  me,"  "  T  must 
shake  my  head  or  else  I  am  in  terror,"  "  I  must  constantly 
say  things,"  "  I  must  .scream  without  wanting  to,  there  is 
that  impulse  in  me,"  "  I  must  throw  myself  about  at  night  in 
bed  as  if  a  strange  power  threw  me,"  "  I  must  turn  round, 
as  when  a  magnet  draws  a  needle,"  "  I  could  not  have  rested 
till  I  had  done  that,"  are  similar  expression.s. 


PSYCHIC  SYMPTOMS  45 

We  may  well  suppose  that  also  the  development  of  such 
stereotypies,  which  later  give  such  a  peculiar  appearance  to 
the  terminal  states  of  the  disease  and  likewise  to  many  forms 
of  idiocy,  is  specially  favoured  by  the  failure  of  healthy 
volitional  impulses,  perhaps  first  made  possible.  Many 
experiences  at  least  indicate  that  the  mechanism  of  our  will 
possesses  arrangements  acquired  long  ago,  which  favour  a 
rhythmical  repetition  of  the  same  discharges ;  their  influence 
will  be  able  to  make  itself  felt  as  soon  as  the  impulses  dis- 
appear which  serve  for  a  realisation  of  intentions. 

Mannerisms.  The  uncertainty  and  weakness  of  the 
volitional  movements  which  are  accompanied  with  conscious- 
ness of  purpose,  and  further  the  ease  with  which  all  possible 
impulses  can  influence  volitional  expression  perhaps  explain 
how  it  is  that  the  actions  of  our  patients  often  end  in 
morbidly  changed  forms.  Even  simple  movements  can  show 
such  changes.  Sometimes  they  are  carried  out  with  too 
great  an  expenditure  of  force,  or  unnecessary  groups  of 
muscles  take  part  in  them,  or  too  much  of  the  limb  is 
employed,  so  that  they  become  ungraceful  and  clumsy ;  or 
they  are  not  rounded  off,  they  begin  and  end  jerkily  and 
appear  therefore  stiff,  wooden,  and  angular.  Other  patients 
again  arrive  at  the  aim  of  the  movement  not  by  the  nearest 
way,  but  by  round-about  ways  with  all  sorts  of  changes 
and  interpolations ;  they  add  flourishes  by  which  the  move- 
ments become  unnatural,  affected  and  manneristic.  Through 
such  peculiarities,  which  are  called  mannerisms,  the  processes 
of  breathing,  speaking  and  writing,  standing  and  walking, 
dressing  and  undressing,  shaking  hands  and  eating,  smoking, 
gestures,  and  the  mode  of  setting  to  work,  can  be  influenced 
and  transformed  in  the  most  manifold  way.  Grasping  is 
done  with  fingers  spread  out  ;  speaking  is  accompanied  with 
loud  hawking  and  grunting  or  with  smacking  movements  of 
the  lips,  the  face  is  distorted  by  spasmodic  grinning ;  among 
masons  every  stone  is  first  turned  round  several  times  before 
it  is  laid  in  position.  Many  patients  lift  their  legs  in  walking 
"  like  the  stork  in  the  lettuce "  ;  a  male  patient  promenaded 
about  with  his  shirt  solemnly  lifted  ;  a  female  patient  played 
the  piano  with  gloves  on. 

The  process  of  taking  food  especially  may  be  changed  by 
the  most  manifold  side  impulses.  Frequently  the  patients 
simply  thrust  their  hands  into  their  plate,  fall  upon  the 
common  dish,  hurriedly  stuff  their  mouths  as  full  as  possible 
and  swallow  their  food  down  almost  without  chewing,  or 
the  spoon  is  grasped  quite  lightly  with  their  finger-tips,  often 
at  the  extreme  end  and  the  handle  is  used  for  eating;  their 


46  DEMENTIA  PR/ECOX 

food  is  invariably  stirred  about  with  their  forks  two  or  three 
times  before  each  mouthful,  the  vegetables  are  divided  into  a 
row  of  equal  little  heaps,  their  hands  are  first  wrapped  up  in 
their  coats,  their  nose  is  stuck  into  the  soup,  or  there  must  be 
a  mouthful  drunk  between  each  two  mouthfuls  of  food  till 
twelve  are  counted  and  so  on.  Others  lap  the  soup  like  a 
dog  or  pour  it  with  profuse  spilling  into  their  mouth  without 
more  ado,  press  the  vegetable  dish  flat  on  to  their  face  and 
steadily  lick  it  clean.  One  of  my  patients  took  hold  of  the 
spoon  quite  correctly  with  the  right  hand,  but  brought  it 
round  her  head  by  the  left  side  to  her  mouth  ;  another  crept 
under  the  bed  cover  at  meals. 

Not  infrequently  the  aim  of  the  action  is  wholly  or  at 
least  partially  frustrated  by  the  changes  and  made  unrecog- 
nisable, so  that  the  impression  arises  of  oddness  and  sense- 
lessness. To  this  group  belong  such  peculiarities  as  giving 
tlie  edge  of  the  hand  or  the  fingertips  in  shaking  hands, 
lying  crosswise  in  bed,  speaking  with  closed  teeth. 
A  patient  covered  himself  with  paper;  another  sucked 
passionately  at  the  corner  of  the  bed,  a  third  dipped  the 
corners  of  his  pillow  into  his  coffee.  All  these  mannerisms 
have  a  pronounced  tendency  to  persist,  and  they  may  form 
part  of  the  behaviour  of  a  patient  without  change  for  decades. 
Through  them  especially  arise  the  half-repulsive,  half- 
ludicrous  impressions  which  strike  the  laity  on  visiting  an 
institution  for  the  insane,  and  it  is  those  therefore  above  all  from 
which  the  popular  picture  of  "  lunatic  "  is  usually  composed. 

It  is  made  still  more  complete  by  the  oddities  in  the 
outer  adornment  of  the  patients,  the  extraordinary  modes 
of  dressing  the  hair,  the  earrings  made  of  pieces  of  wire,  the 
gay  ribbons  in  the  hair  and  in  the  button-hole,  the  peculiar 
ornaments  of  the  clothes.  A  patient  drew  his  socks  over  his 
trousers ;  another  wore  them  folded  together  on  his  head  ;  a 
third  adorned  himself  with  bracelets  of  paper.  Frequently 
also  the  patients  adopt  very  peculiar  attitudes  and  deportment, 
balance  themselves  on  one  leg,  put  their  head  between  their 
legs,  lie  on  the  edge  of  the  bed,  spread  out  their  arms  in 
cruciform  attitude,  twist  themselves  together  in  the  most 
remarkable  manner.  A  patient  answered  as  follows  to  the 
question  why  he  did  such  things: — 

"The  feeling  is  called  forth  by  influence  from  the  outer  world.  It  is 
then  as  if  with  certain  degrees  of  unity  of  the  small  parts  with  no 
reasonable  handling  by  oneself  small  parts  of  the  body  (at  the  finger 
and  other  limbs)  were  pulled  away  from  the  entire  whole  with  unspeakable 
pains.  If  I  feel  anywhere  in  my  body  much  discomfort,  which  it  with 
Its  whole  mental  ability  must  endeavour  to  put  right,  in  order  not  to  will 
to  produce  these  extraordinary  pains,  I  must  change  my  position  in  all 
the  small  parts." 


PSYCHIC  SYMPTOMS    "  47 

Parabulia. — Gradual  transitions  from  the  simple  changes 
of  ever)'-day  purposeful  actions  lead  .to  those  disorders  of 
volition  which  we  may  gather  together  under  the  name  of 
parabulia.  The  side  impulses  which  at  first  bring  about  only 
flourishes  in  action  may  gradually  become  cross  impulses 
which  lead  to  complete  derailment  of  volition.  Some 
examples  belonging  to  this  class  we  have  already  brought 
forward  in  which  to  a  certain  extent  a  distorted  picture  of 
natural  actions  arises  by  the  employment  of  unsuitable 
means.  But  further,  an  actio;i  at  first  perhaps  correctly 
begun  is  turned  away  in  quite  another  direction  by  cross, 
impulses  or  perhaps  simply  stopped  before  completion 
(Ergodialeipsis  according  to  Moravsik).  The  hand  that  will 
stretch  out  and  take  hold  of  the  spoon,  goes  to  the  nose  to 
scratch  there;  the  patient  who  will  put  on  his  coat,  puts  his 
legs  into  the  sleeves.  In  shaking  hands  the  movement  comes 
to  a  standstill  halfway;  the  patient  breaks  off  in  the  middle 
of  a  sentence  ;  he  stirs  his  food  about  keeping  time  as  he  does 
so,  without  bringing  the  fork  with  food  on  it  to  his  mouth. 

Whether  we  have  here  to  do  with  the  turning  away  of 
actions  in  a  different  direction  or  with  the  stopping  before 
completion  of  actions  already  begun,  the  cross  or  contrary 
impulse  can  further  suppress  the  volitional  movement  itself 
even  as  it  is  already  coming  into  being,  so  that  the  action 
which  is  about  to  be  done  is  not  even  begun,  but  from  the 
outset  is  replaced  by  another  or  simply  suppressed.  The 
patient  who  is  to  show  his  tongue,  opens  his  eyes  wide 
instead,  he  flings  the  cup  away  instead  of  putting  it  to  his 
mouth.  We  shall  consider  these  "  parergasias "  more  in 
detail  in  the  discussion  of  the  movements  of  expression. 

Negativism. — By  far  the  most  important  form  of  para- 
bulia is  the  suppression  of  volitional  movements  by  contrary 
impulses,  negativism.  It  is  natural  that  of  the  innumerable 
side  impulses  which  in  themselves  are  possible,  those  should 
take  up  a  special  position  which  are  exactly  contrary  to  the 
attainment  of  the  end  in  view ;  on  the  appearance  of  a 
volitional  intention  they  are  at  the  same  time  most  strongly 
stimulated  in  consciousness  by  the  action  of  contrast. 
Negativistic  obstruction  of  volition  plays  therefore  an 
extraordinarily  large  role  in  the  clinical  picture  of  dementia 
praecox.  To  begin  with  it  leads  to  the  instinctive  suppression 
of  all  reaction  to  external  influences,  further  to  stubborn 
opposition  to  interference  of  all  sorts,  and  in  the  end  to  the 
performance  of  actions  which  are  exactly  opposed  to  those 
which  are  suggested  by  the  circumstances  or  required  by  the 
environment. 


48  DEMENTIA  PRECOX 

It  is,,  however,  certain  that  the  disorders  commonly- 
collected  under  the  term  negativism  have  not  all  the  same 
origin,  as  Bleuler  ^  in  particular  has  shown  in  detail.  At  first 
insane  ideas  or  ill-temper,  especially  anxiety  or  irritability^ 
cause  the  patients  to  shut  themselves  up  from  their  environ- 
ment. They  do  not  touch  their  food  because  they  think  it 
is  poisoned,  do  not  lie  down  in  bed  because  they  imagine 
that  they  are  threatened  with  the  danger  of  syphilitic  infection 
there,  d^o  not  shake  hands  because  they  distrust  the  physician, 
or  fear  his  influencing  them,.and  they  will  not  have  anything 
to  do  with  ,  him.  In  a  similar  way  probably  one  should 
regard  the  resistant  attitude  of  the  bewildered  and  confused 
patients  to  whom  everything  appears  changed,  incom- 
prehensible, and  mysterious  ;  here  also  anxious  distrust  may 
be  as-umed  as  the  mainspring  of  their  opposition.  In  none 
of  these  cases  is  it  a  question  of  negativism  in  the  sense  of  a 
disorder  specially  peculiar  to  dementia  pr?ecox.  It  appears 
to  me  also  that  the  behaviour  of  such  patients  towards  the 
stimuli  which  they  encounter  does  not  differ  from  that  of 
other  anxious  or  irritable  persons  ;  in  especial  on  stronger 
provocation  they  fall  into  excitement,  make  lively  movements 
of  defence,  or  even  pass  over  to  attack. 

Various  experiences  meantime  indicate  that  there  is 
another  form  of  resistance  to  outside  influences,  which  comes 
into  existence  wholly  by  impulse  that  is  without  foundation 
on  ideas  or  emotions.  Imperative  negativism,  the  carrying 
out  of  action  exactly  contrary  to  that  wished,  scarcely  allows 
of  any  other  interpretation.  Only  exceptionally  could  there 
be  any  palpable  motive  in  the  question,  as  when  a  patient 
forces  his  way  out  on  being  told  to  stay  where  he  is.  But 
when  a  patient  begins  to  sing  as  soon  as  he  is  asked  to  be 
quiet,  when  he  goes  backward  on  being  ordered  to  march, 
it  is  difficult  to  find  an  explanation  in  deliberation  or 
emotional  influences.  To  this  it  may  be  added  that  the 
patients  in  many  cases  of  marked  negativism  actually  exhibit 
neither  delusions  nor  emotions,  which  could  in  any  way 
justify  their  peculiar  behaviour.  But  finally  for  this  question 
the  utterances  of  the  patients  themselves  are  very  important 
which  are  almost  always  to  the  effect  that  they  felt  them- 
selves forced  without  being  able  to  explain  the  reasons  to 
themselves.  "  I  must  often  do  the  opposite  of  what  I  am 
asked,"  said  a  patient,  "  I  do  not  will  as  the  people  will," 
explained  another.  Certainly  here  and  there  delusions  or 
hallucinations  are  mentioned  as  causes  of  the  negativistic 
behaviour.     The  patients  feel  themselves  under  a  "  ban,"  eat 

'Bleuler,  Psychiatrisch-Ncurol.  Wochenschr.  xii.,  i8. 


PSYCHIC  SYMPTOMS  49 

nothing  for  a  day  "  because  God  does  not  wish  them  to," 
"  must  not  speak,"  "  remain  lying,"  "  on  a  higher  command," 
"because  the  mediums  wish  it,"  "the  voices  command  it." 
It  may,  however,  rightly  be  assumed  that  such  reasons  are 
nothing  else  than  formulas  for  the  characterisation  of  hin- 
drances to  volition  which  are  inexplicable  to  the  patient ; 
the  voices  also  might  in  this  respect  only  give  expression  to 
what  the  patient  feels  in  himself 

Still  more  distinct  does  the  peculiarity  of  this  disorder 
become  by  the  fact  specially  emphasised  by  Bleuler  of 
"  inner  negativism."  As  already  mentioned  above,  obstacles 
place  themselves  in  the  way  not  only  of  external  commands, 
but  also  of  the  internal  volitional  impulses,  obstacles  which 
lead  sometimes  only  to  the  omission  of  the  intended  action, 
but  also  to  the  performance  of  a  contrary  one  or  even  of  an 
action  of  a  totally  different  kind.  "  I  never  arrive  at  what  I 
want  to  do,"  said  a  patient,  "  I  cannot  do  what  I  wish,"  "  I 
had  no  free  will,"  "  I  had  to  do  something  without  myself 
wishing  to,  sometimes  to  go  backwards,"  "  I  had  to  do  what 
was  repugnant  to  my  character,""  Reason  fights  against  the 
external  influence,"  others  explain.  Also  "  intellectual 
negativism,"  which  has  already  been  discussed,  the  appear- 
ance of  negativistic  hindrances  in  the  train  of  thought,  can 
scarcely  be  otherwise  explained  than  by  immediate  disorders 
of  that  inner  activity  of  volition  which  regulates  the  rising 
into  consciousness  and  the  connection  of  ideas. 

Autism. — The  clinical  phenomena,  in  which  negativism 
shows  itself,  are  extremely  varied.  It  is  a  common  experience 
that  the  patients  with  dementia  praecox  are  more  or  less 
inaccessible,  that  they  shut  themselves  off  from  the  outer 
world.  Bleuler  has  described  this  important  symptom  as 
autisni.  The  refusal  of  all  psychic  contact  is  often  shown  in 
the  whole  behaviour  of  the  patients  as  soon  as  one  begins  to 
occupy  oneself  with  them.  They  do  not  look  up  when 
spoken  to,  perhaps  turn  away  their  head,  or  turn  their  back 
directly  to  the  questioner.  The  hand  offered  in  greeting  is 
refused,  "  It  is  not  proper,"  "  In  bed  the  hand  is  not  given," 
"  Only  women  greet  each  other  that  way,"  say  the  patients  ; 
they  have  given  the  hand  too  often  formerly.  Many  patients 
close  their  eyes,  cover  their  faces  with  their  hands,  cover 
themselves  up,  draw  the  bedcover  over  their  head,  and  con- 
vulsively hold  it  fast ;  "  This  position  is  pleasant  for  the 
eyes  and  more  restful  for  the  inner  life,"  explained  a  patient. 
Often  the  patients  refuse  all  information  ;  "  That  is  their  own 
affair,"  "  That  is  no  one's  business,"  "  People  are  cross- 
questioned  in  that  way,"  "They  should  not  be  there,  did  not 

D 


50  DEMENTIA  PR/ECOX 

require  to  give  explanations."  A  patient  first  asked  the 
physician  to  show  him  his  diplomas  that  he  might  know 
with  whom  he  had  to  do.  Others  give  perverted  or  quite 
insufficient  answers. 

Stupor. — Hut  even  when  they  do  express  themselves,  one 
notices  very  distinctly  by  their  niggardly,  resisting,  forced 
statements  which  tell  nothing,  the  resistance  which  they 
oppose  to  any  searching  into  their  inner  life.  Frequently  the 
patients  have  already  shut  themselves  off  from  their  family 
and  their  surroundings  long  before  the  appearance  of  the 
more  striking  symptoms,  say  only  the  most  necessary  things, 
do  not  appear  any  more  at  the  common  meals,  avoid  all 
friendly  intercourse,  bolt  themselves  in,  take  lonely  walks. 
They  bluntly  refuse  visits  from  the  physician  and  friendly 
relations  with  their  fellow-patients.  As  the  disorder  becomes 
further  elaborated  there  is  developed  the  picture  of  negati- 
vistic  stupor,  the  rigid,  impenetrable  shutting  up  of  themselves 
from  all  outer  influences,  which  is  connected  with  a  suppression 
driven  to  the  limit  of  the  possible  of  all  natural  emotions.  We 
shall  later  have  to  describe  the  clinical  picture  in  detail. 

Causation  of  Negativism. — As  has  already  been  indicated 
in  the  general  part,  the  understanding  of  negativism  in  the 
sense  here  depicted  requires  to  be  connected  with  the  fact 

that    our    thinking    and Q.cting    constantly  have    to    make 

decisionS-^^Between  diflereiit^  often  contrary,  ideas  and 
volitioijal_  resolves.  ?  1  n~'esp?ecial  ""ou?"  whole-retationslTip^  to 
the  environ metiTis  governed  throughout  by  volitional  move- 
ments of  inclination  and  disinclination,  and  the  suitable 
choice  of  these  possesses  fundamental  importance  for  our 
existence.^  lileuler  speaks  of  an  "ambivalence"  and  an 
"  ambitenciency "  of  psychical  processes,  in  the  .sense  that 
they  are  accompanied  at  the  same  time,  by  contrary  emotional 
stresses  and  can  lead  to  contrary  emotional  movements.  /  He 
assumes  on  the  basis  of  his  experiences  that  this  discord  in 
feelings  and  impulses  comes  under  observation  specially 
frequently  and  strongly  in  dementia  pra^cox,  and  forms  an 
important  foundation  for  the  development  of  negativism.  ^ 

But  of  course  even  if  that  discord  be  granted,  still 
further  explanations  are  needed,  not  indeed  why  the  choice 
between  resistance  and  yielding  oscillates  in  an  unaccount- 
able wa)'  which  certainly  often  enough  happens,  but  why  so 
frequently  during  a  long  period  the  negativistic  movements 
govern  tlie  sum  total  of  the  actions  in  so  decided  a  way. 
So  far  as  morbid  moods  or  delusions  play  a  part,  I  believe, 
as  has  been  mentioned  alx>ve,  that  it  is  not  a  case  of  genuine 
negativism.      At  most  it  might  be  admitted  that  with  their 


PSYCHIC  SYMPTOMS  51 

help  the  tendency  to  the  appearance  of  ne<,'ativistic 
phenonnena  which  is  present  in  any  case,  may  be  strengthened, 
as  conversely  negativism  perhaps  also  exercises  some 
influence  on  the  content  of  hallucinations  and  delusions,  as 
on  the  tone  of  the  mood. 

In  the  last  place,  however,  there  must  be  other  causes 
which  determine  the  governing  position  of  the  contrary 
impulses,  because  of  their  instinctive  origin  and  their 
independence  of  the  remaining  contents  of  conscjousness. 
^  Besides  erotic  emotions  which  are  usually  even  in  healtTiy 
life  already  accompanied  by  discordant  processes  of 
emotion  and  volition,  Bleuler  regards  as  such,  principally 
the  "  autistic "  tendency  of  the  patients  to  withdraw  them- 
selves into  themselves,  the  existence  of  specially  sensitive 
"  life  traumata,"  and  the  "  forcing  of  thoughts,"  the  deficient 
command  over  the  train  of  thought.  He  reckons,  however, 
for  the  explanation  of  "  inner  negativism  "  also  with  influences 
unknown  as  yet. 

The  significance  of  erotic  emotions  is  in  my  opinion  to 
be  judged  of  in  a  similar  way  to  those  other  feelings  and 
therefore  to  be  left  out  of  account  in  the  fundamental 
explanation  of  genuine  negativism.  That  in  the  behaviour 
of  the  patients  "  life  traumata "  play  a  part  to  any  great 
extent,  so  that  they  shut  themselves  up  from  their  surroundings 
as  a  protection  from  contact  has,  as  I  believe,  till  now  neither  ^^ 
been  proved  nor  even  made  probable ;  Valso  the  fact  that  C  ^~^ 
negativism  frequently  appears  and  disappears  so  suddenly;  )  """^^ 
■/''■Sgginri^  to-me'To  alrgue  very  much  against  such  an  interpretation.  \ 
In  contrast  the  "autism"  of  the  patients  stands  certatiTTy  t 
without  doubt  in  near  relation  to  their  negativism,  only  I 
should  think  that  it  represents  not  so  much  a  cause  but  much 
rather  a  manifestation  of  negativism.  The  tendency  to  shut 
themselves  off"  from  their  surroundings  is  frequently  found 
in  our  patients  already  many  years  before  the  real  onset  of 
the  disease  and  it  is  a  very  common  phenomenon  in  the 
terminal  states.  But  I  very  much  doubt  if  it,  as  Bleuler 
thinks,  is  caused  by  the  withdrawal  of  the  patient  to  his 
own  phantasies,  and  if  he  on  this  account  feels  every  diverting 
of  attention  as  an  intolerable  disturbance.  Stubborn  inac- 
cessibility is  often  enough  shown  by  patients  on  tTTe~^ne 
Iraiid,  in  whom  there  can  be  no  thought  of  special  imaginings 
in  which  they  could  lose  themselves,  and  it  is  lacking  on  the 
other  hand  in  innumerable  other  delusional  forms  of  disease, 
as  specially  in  paralysis  in  which  the  patients  certaintly  do 
dream  themselves  into  a  world  of  imaginings  which  are 
greatly  disturbed  by  the  influences  of  the  surroundings. 


52  DEMENTIA  PR.^COX 

Vlt  seems  far  more  probable  to  me  that  negativism 
and  "  autism  "  which  is  only  its  forerunner,  are  not  at  all 
connected  with  ideas  or  "complexes,"  but  with  the  general 
^  constraint^  of  volition  which  is  so  specially  peculiar  to 
i,  dementia  pr.-ecox.  \  Already  on  the  most  varied  occasions 
we  have  had  to  pomt  to  the  fact  that  the  patients  lose  the 
mastery  over  volition  and  often  feel  this  profound  disorder 
more  or  less  distinctly.  They  are  heard  describing  their 
inner  constraint  always  in  new  and  ernphatic__expi:sssions. 
Their  will  has  been  taken  from  them ;  it  is  weak,  they  have 
no  will  of  their  own  any  more,  are  not  masters  over  it  ;  there 
is  no  independence  in  them.  "  I  am  not  melancholy,  and 
not  .senseless."  said  a  patient,  "  I  only  lack  a  will  of  my  own, 
an  impulse  of  my  own."  The  patients  feel  themselves  not 
free,  influenced,  dominated  by  external  will,  by  invisible 
might,  by  magic  powers  possessed  b)'  superhuman  beings 
"like  an  automaton"  ;  they  suffer  from  "  auto-su£fgp«itjnn  ap^ 
high  grade  suggestibility."  stand  "  as  under  compulsioii,"  are 
in  "^slavery  to  suggestion  "  ;  "I  am  a^milll  nildfcr  cominllsion," 
explained  a  patient.^  An  external  force  has  power  over 
them  under  whose  ban  they  must  wholly  exist  and  act ; 
they  must  do  what  others  wish,  other  people  have  power 
over  them ;  "  Another  person  works  in  me  ;  who  that  is,  I 
do  not  know,"  .said  a  patient.  Another  complained,  "  For 
a  year  I  have  no  longer  had  any  will  of  my  own,  I  am 
dependent  on  other  people ;  my  will  becomes  weaker  from 
day  to  day  ;  it  is  a  dreadful  bungling  of  work  ;  1  have  no  power 
to  begin  another  life."  A  servant  girl  said  she  got  orders  as 
if  she  were  in  a  situation,  she  was  already  accustomed  to  it. 

Sometimes  the  influence  on  volition  is  referred  to  certain 
sources.  God  leads  the  patient ;  the  patient  is  wholly  under 
the  influence  of  a  companion ;  he  "  must  do  what  his 
brother-in-law  suggests  to  him  by  thought-transference  by 
electrical  means."  A  female  patient  felt  herself  ruled  "  by 
a  gentleman  and  a  lady,"  another  by  her  fianc^  who  used 
enchantments  and  mystic  measures  in  order  to  fetter  her ; 
still  another  noticed  that  a  gentleman  who  passed  had 
power  over  her.  A  patient  thought  that  people  were  sent 
to  him,  who  were  to  study  suggestions,  and  they  gradually 
went  over  to  hypnosis  ;  experiments  were  being  tried  on 
him;  another  saw  an  "eye  like  a  half-moon,  and  had  to 
follow  it,  he  had  sworn  to."  One  of  my  patients,  who 
thought  he  was  put  on  trial  by  the  authorities,  asked  them  in 
thought  often  and  urgently  now  at  last  to  make  an  end  of  it  ; 
he  crossed  the  French  frontier  in  order  to  see  if  there  also 
the  suggestions  took  place.     When  he  had  convinced  himself 


PSYCHIC  SYMPTOMS  53 

that  the  currents  went  over  the  frontier,  probably  by  railways 
and  telegraphs,  he  had  only  the  one  wish  left,  to  cross  the  sea 
in  order  to  take  his  life  in  case  the  action  at  a  distance  could 
be  carried  over  also  by  cable. 

We  have  already  mentioned  that  even  the  isolated 
peculiar  acts  are  caused  as  a  rule  without  further  motive  by 
irresistible  impulses.  The  patient  "  must "  lie  down,  "  assume 
a  strange  appearance,"  "  spit  on  the  physician,"  "  assume 
attitudes,"  walk  till  he  can  "walk  no  longer,"  "by  order"  run 
from  one  place  to  another,  imitate  everything,  laugh,  "even 
^hen  he  is  sad  " ;  he  "  can  do  nothing  against  it,  he  must 
scratch  his  face ;  "  that  is  caused."  A  female  patient 
complained  there  was  something  wanting  in  her  head  ;  her 
understanding  was  weak ;  she  therefore  "  talked  stupidly, 
was  really  insane,  had  to  do  such  things  from  want  of 
sense."  Here  and  there  the  impulses  take  on  the  form  of 
auditory  hallucinations  without  the  nature  of  the  process  being 
thereby  essentially  altered  ;  voices  summon  the  patient  to  do 
this  or  that,  and  he  "  must  do  all  that  they  ask." 

Personality. — From  these  and  similar  utterances  of  the 
patients  it  clearly  follows  that  their  thinking,  feeling,  and 
acting  have  lost  the  unity  and  especially  that  permanent 
inner  dependence  on  the  essence  of  the  psychic  personality, 
which  provides  the  healthy  human  being  with  the  feeling  of 
inner  freedom  ;  "  I  can't  get  hold  of  my  will,"  said  a  patient. 
We  may  assume  that  this  profound  change  in  the  psychic 
life,  which  indicates  a  complete  destruction  of  the  personality, 
must  in  itself  influence  the  attitude  towards  the  outer  world 
in  the  most  decisive  way.  The  most  natural  protective 
measure  of  the  weak  consists  in  shutting  himself  up  and 
hiding.  The  more  or  less  distinct  feeling  of  inner  constraint 
and  powerlessness  which  accompanies  our  patients  along  with 
childish  susceptibility  to  influence,  could  therefore  on  the 
otheV  hand  play  an  essential  part  in  the  development  of  their 
obstinate  seclusion.!  If  the  disorder  of  volition  can  influence 
the  conduct  of  the  patients  in  both  directions  and  if  it  at  the 
same  time  makes  it  more  difficult  for  them  to  hold  fast  to  a 
uniform  attitude  towards  their  surroundings,  we  should  also 
have  come  nearer  to  the  understanding  of  the  frequent 
oscillations  between  heightened  sensitiveness  to  influence  and 
stubborn  negativism.  /  It  is  self-evident  here  that  we  must 
not,  as  has  already  'been  pointed  out,  think  of  conscious 
deliberation.  Much  rather  is  it  the  general  change  of  the 
personality  and  its  behaviour  towards  the  ordinary  events  of 
life  that  come  into  consideration  as  it  is  conditioned  by  the 
perception  of  its  own   inner   want  of  independence.     If  one 


54 


DEMENTIA  PR/ECOX 


wishes,  one  may  with  more  right  in  my  judgment  regard  the 
feeling  of  the  destruction  of  the  ivili  which  may  precede  the 
real  onset  of  the  disease  under  certain  circumstances  certainly 
by  many  \ears,  as  a  "  life  trauma  "  which  cannot  endure  any 
contact  and  therefore  causes  the  patient  to  shut  himself  up. 
rather  than  the  influence  of  other  chance  events  of  life.     That 


Fig.  S.     A  handkerchief  embroidered  with  silk. 

disorder  would  also  to  a  certain  extent  explain  the  tendency 
of  many  of  the  patients  to  spin  themselves  round  with 
imaginings ;  he  who  is  not  able  to  control  his  own  will  and 
with  it  his  life,  gladl)-  takes  refuge  in  the  realm  of  dreams. 

Practical  Efficiency. — As  the  mental,  so  also  the  practical 
efficiency  of  the  patients  is  invariably  greatly  encroached  on 


PSYCHIC  SYMPTOMS 


55 


by  the  disorders  of  volition.  They  come  to  a  standstill  at 
every  difficulty,  must  always  be  driven  on  again,  work 
extremely  unequally,  do  a  great  deal  of  their  work  wrongly, 
are  completely  unreliable,  spoil  material  and  tools.  At  the 
same  time,  however,  a  certain  technical  skill  can  be  preserved. 
In  their  handiwork  the  loss  of  taste  often  makes  itself  felt  in 
their  choice  of  extraordinary  combinations  of  colour  and 
peculiar  forms.  The  accompanying  figure  gives  an  example 
of  the  singular  works  of  art  of  the 
patients  ;  it  represents  a  handkerchief 
embroidered  with  thick  silk.  I  also 
reproduce  in  Fig.  9  a  stocking  which 
was  knitted  by  a  patient  who  had  had 
catatonic  stupor  for  years.  The  measure 
placed  beside  it  is  20  cm.  The  patient 
knitted  for  a  number  of  days  simply  a 
long  pipe,  and  then  when  she  was  told 
brought  the  stocking  at  last  to  an  end. 
She  next  added  the  two  remarkable 
loops  and  further  the  point.  At  the 
same  time  the  work  was  without  fault 
in  detail.  Many  patients  produce  very 
queer  handiwork,  a  glove  made  of 
human  hair,  linen  coverings  for  horses' 
hoofs,  dolls  made  of  cotton  wool.  The 
musical  performances  of  the  patients 
also  show  distinctly  the  decline  of  fine 
artistic  feeling  as  they  play  sometimes 
without  expression,  sometimes  in  an 
arbitrarily  incorrect  way.  After  the 
more  stormy  manifestations  have  run 
their  course,  it  is  often  possible  to 
educate  the  patients  again  to  simple 
work  which  they  then  accomplish  with- 
out circumspection  or  self-reliance,  and 
often  with  all  sorts  of  caprices,  but  still 
with  the  regularity  of  a  machine.  A 
few  patients  continue  work  without 
showing  any  sign  of  fatigue  or  annoy- 
ance, till  they  are  told  to  stop. 

Self-expression. — The  general  disorders  of  volition  often 
take  many  peculiar  forms  in  the  movements  of  expression  of 
the  patients.^  The  cessation  of  the  need  to  express  oneself 
corresponds  to  tKe  disappearance  of  volitional  activity.     The 

^  Mignot,  Annales  medico-psychol,  1907,  II.   i.   Morawsik,  Allgem.   Zeitschr. 
Psychiatric,  1907,  733. 


1  ig-  9- 
Singular  stocking  (Catatonia). 


56  DEMENTIA  PR.'ECOX 

patients  become  monosyllabic,  sparing  of  their  words,  speak 
hesitatingly,  suddenly  become  mute,  never  relate  anything  on 
their  own  initiative,  let  all  answers  be  laboriously  pressed  out 
of  them.  They  enter  into  no  relations  with  other  people, 
never  begin  a  conversation  with  anyone,  ask  no  questions, 
make  no  complaints,  give  their  relatives  no  news.  They 
write  no  letters  or  only  those  with  almost  nothing  in  them, 
stop  after  writing  a  few  lines.  Their  facial  expression  also  is 
vacant  and  dull  ;  their  gestures  are  limp,  few,  and  monotonous. 
On  this  foundation  echol^lia  easilyappears.  which  makes 
itself  known  in  the  involuntary  repetition  of  questions  asked 
or  other  things  said  to  them,  as  well  as  in  the  introduction  of 
fragments  of  speech  caught  up  into  their  own  utterances. 

In  the  states  of  excitement  in  place  of  taciturnity  a  pro- 
digiou^_/fgtc^  of  talk  may  appear  which  does  not  correspond 
to  a  need  for  expression,  but  usually  unburdens  itself  without 
anxieferenceTo  the  surroundings.  Often  it  consists  of  out- 
^ur.sts  of  filthy  abuse,  piercmg  shrieks  or  singing  ;  a  patient 
whistled  tunes  all  day  on  a  water-bottle ;  many  patients 
carry  on  monologues  or  answer  voices  loud  out,  often  cursing 
and  abusing,  especially  in  the  night.  The  following  is  a 
record  of  a  fairly  lively  dialogue  of  this  kind,  which  a  patient 
carried  on  with  his  voices  : — 

"What  does  it  matter  to  me  tlien  what  you  think  !  That  has  nothing 
to  do  with  me,  is  in  the  highest  degree  indifferent  to  me. — What?  I 
must  think  that?  That  I  must  not  at  all.  I  can  think  what  I  like,  and 
you  think  what  you  like  I — That  would  be  still  better?  No,  that  would 
not  be  better  at  all  I  I  can  certainly  do  with  my  head  what  I  will  I  I 
must  wholly  misunderstand  you  I  That  is  entirely  your  affair  if  you 
share  your  thoughts  with  me  !  It  is  not  I  who  am  ill.  -You  are  the 
patient  I  I  am  a  real,  sensible  person,  and  the  superintendent  is  carrying 
on  the  most  infamous  game,  is  carrying  on  criminal  fabrication  ! — What? 
Am  I  to  shoot  myself?  I  don't  think  so  I  Shoot  yourself  if  you  like  I 
I  am  not  going  to  do  you  this  pleasure  I — What?  I  am  stupid?  No 
you  are  stupid  ;  I  am  cleverer  than  you  all  !  I  am  too  clever  for  you  ; 
that's  why  you  want  to  keep  me  in  here — It  doesn't  helj)  me  at  all? 
We'll  see  that,  if  it  doesn't  help  I  There  is  still  a  Bavarian  State  with 
guaranteed  rights,  and  you  will  be  put  in  jail  I  As  far  as  I'm  concerned 
lick  me I  " 

Incoherence  of  the  train  of  thought,  as  we  have 
already  depicted  it,  is  usually  distinctly  noticeable  in  the 
conversation  of  the  patients.  The  most  different  ideas 
follow  one  another  with  most  bewildering  want  of  connection, 
even  when  the  patients  are  quite  quiet.  A  patient  said  "  Life 
is  a  dessert-spoon,"  another,  "  We  are  already  standing  in  the 
spiral  under  a  hammer,"  a  third,  "  Death  will  be  awakened 
by  the  golden  dagger."  a  fourth,  "The  consecrated  discourse 
cannot  be  over  split  in  any  movement,"  a  patient,  "  I  don't 


PSYCHIC  SYMPTOMS 


57 


know  what  I   am  to  do  here,  it  must  be  the  aim,  that  means 
to  steal  with  the  gentlemen." 

The  page,  which  is  reproduced  as  a  specimen  of  writing 


X7^^f^- 


^l^^l^l^T*'  ^^y  -»^.»f-»y^ 


Specimen  of  writing  i.  Incoherence. 

No.  I  with  notes  of  a  patient,  as  he  used  to  produce  them 
in  large  number,  gives  a  good  impression  of  this  incoherence. 
The  arrangement  of  the  notes,  the  handwriting  changing  in 


58 


DEMENTIA  TR/ECOX 


size  and  form,  the  irregular  grouping,  the  underlining  of 
different  kinds  and  colours  make  it  appear  peculiar  and 
incomprehensible.  In  detail  we  have  a  varied  mixture  of 
broken  words  and  fragments  of  sentences  before  us,  among 
which  there  is  no  connection  whatsoever.  We  only  notice 
the  recurrence  of  single  parts  ("  Bau,"  "  baum,"  "  Hauptbau/ 
"  Charakter,"  "  Wortschatzbuch,"  "  Wort-stiel-baum,"  "  Geist- 
Stoff,"  "Haft,"  " wahrhaftigste,"  "fort").  The  affected  use 
of    hyphens   is    further    noticeable   ("  Bau-m,"   "Grama-tik," 


''•**^, 


-^*«--^<4^  1  -n  \>  >>  f////?f^ 


Specimen  of  writing  2.  Incoherence  wiili  Stereotypy. 

"  Or-tho-graphie  ")  and  of  marks  of  exclamation  ("  ! !  Weide  ! !," 
"  ! !  Werde : !  "),  and  the  writing  above  the  line  of  the  last 
letters  in  numerous  words,  and  lastly  among  the  other  notes 
the  curiously  encouraging  remark  "  (sig-ste-was??),"  and 
"grundfalsch  "  written  with  a  flourish  across  it. 

Still  more  incoherent  is  the  above  piece  of  writing. 
(Specimen  of  writing  2.)  Here  there  are  certainly  still  .some 
connected  words  decipherable  ("the  day's  no  longer  far  off 
and    the  night  greets    us   again,"    "  salutation    and   blessing 


PSYCHIC  SYMPTOMS 


59 


from  the  apostolic  over"),  but  intermixed  there  are  irregularly 
strewn  incomprehensible  aggregations  of  letters,  childish 
drawings,  single  signs  like  letters  and  numbers,  a  group  of 
similar  strokes,  which  let  the  tendency  to  persistence  of 
the  movements  of  writing  appear  clearly,  as  do  also 
the  words  that  return  in  various  forms,  "Juden,"  "  Gus- 
Gruss-Grund,"  "  Hohen-Hoch-Hohre."  The  extraordinary 
irregularity  of  the  hand-writing  should  also  be  noticed  here. 

In  the  drawings  of  the  patients  also  there  invariably 
appears  on  the  one  hand  incoherence,  on  the  other  hand 
persistence  of  impulse  to  movement.  Fig.  lo  reproduces 
one   of   the   senseless,   childish    drawings    which    a    patient 


Fig.  lo.     Drawings  in  Dementia  Priecox  (Metamorphoses). 

produced  in  large  numbers  daily ;  there  are  wonderful 
combinations  of  strokes  and  flourishes  with  hints  of  stereo- 
typy. They  correspond  completely  with  what  Pfersdorfif 
has  named  metamorphoses ;  there  were  endless  variations 
of  the  same  recurring  fundamental  form. 

The  second  example,  Fig.  ii,  gives  the  impression  at  the 
first  glance  of  a  pen  and  ink  drawing.  It  is  composed, 
however,  of  senseless  combinations  of  strokes.  Besides  these 
there  are  notes  with  written  verbigeration,  enumerations  and 
plays  on  words  ("  Irre-Irrengarten  -  Irrenspaziergange, 
Irrenreichman  "  and  so  on,  "  Irrenwurz,  Eierwurz,"  "  Abtritt- 
Pissoir,  Latrine-Scheisskerle,"  "Lukretia,  Metardus,Onophrius, 
Primus-Benignus ").  Such  expressions  of  quite  divergent 
stamp  are  interpolated  in  the  most  elegant  and  regular  hand- 


6o 


DKMKXTIA   PR/KCOX 


writing.  The  third  example  also  (Fig.  12)  shows  besides  the 
startHng  senselessness  antl  tastelessness  of  the  design,  the 
monotonous  recurrence  of  the  same  details,  and  lastly  the 
incoherent  inscriptions  in  which  "  Scmiramus,"  "  Jeremias," 
"  Apollo"  are  joined  with*'  Ludowicum  Napoleon,"  "  Markus," 
*'  Chamisso  "  and  "  Woltaires." 


■   aUf^u'::-'-  ^  *^'       ^  Jry<  ^-f  >^ 


f. 


r 


'I'J^'^^^v;^  '. 


I'ig.  II.     Senseless  Drawing. 

Similarity  in  Sound  can  be  recognised  here  and  there  as 
a  certain  link  in  the  disconnected  utterances  of  the  patients. 
They  rhyme,  "  Ott  Gott,"  "simbra-umbra  "  ;  they  play  sense- 
lessly with  words  and  sounds.  A  patient  spoke  of  "  Khebrechcr 
and  Heinbrecher,"  another  of  "  verhort  und  verstort,"  a  third  of 
"  Sauspiel  and  Schauspiel."     A  fourth  explained  his  spitting 


.    v.:  \ 


Fig.   12.  Queer  Drawing. 


62  DEMENTIA   PR/ECOX 

with  'Zurtuss,  Eiiifluss,  and  Ausfluss";  a  fifth  said  "jet/.t 
miissen  Sie  mich  herunteifragcn.damit  es  wieder  heruntergeht." 
a  sixth,  "  Ich  bin  der  Hesitzer  und  Ihr  seid  die  Schwitzer  " ; 
a  seventh  wished  "  Vorrichten  statt  Nachrichten  "  ;  an  eighth 
called  himself  "  Gottes  Sohn  und  Gottes  Schwur"  ;  a  patient 
spoke  of  Albicocca,  Kokken,  Kokain. 

How  the  train  of  thought  may  be  interrupted  by  meaning- 
less plays  on  words  is  shown  b\'  the  following  passage  which 
was  written  by  a  young  patient  who  amused  himself  a  great 
deal  with  writing : — 

"d.i  droben  auf  dem  Ciebirge  war  einmal  ein  Jager  aufgefunden 
worden.  Auf  der  Felsenwand  in  der  Niihe  der  Sennhiitte,  Senner  und 
Sennerin  hat  ein  eines  schonen  Tages  ein  von  F'elsenwand  achasant 
drihahol  di  ietal  am  droben  auf  der  Wand.  Vesuv,  Vilz,  Ventus,  Verlend, 
Vaterland,  Wist,  Vogel.  Veinstningerstadt,  Venus,  Vondertan  Vogt, 
Vugler,  Vangfiscb,  Vidtrich,  V'ersendung,  Viendling,  Vach,  Vieh, 
Viehzucht,  \'ersicherung,  V'elzler,  Vanter,  Ente,  Entrich,  Elsass, 
Erlangen,  Eidling,  EidscJuvur,  Eid,  Endlang,  Esel,  Ellenbogen,  Eiter, 
Edling,  Entdeckung,  Erfindung,  Erdboden,  Erdenhiigel,  Erdenwall, 
Engel.  (Tliere  follow  still  forty-seven  words  beginning  with  E,  partly 
(|uite  senseless,  then  thirty-two  words  with  U,  thirty-five  with  K  ;  then 
comes  DieWachtam  Rhein,  "Morgenrot,"  "Zu  Strassburgauf  der  Schanz," 
"  Ich  hab'  mich  ergeben,"  "  Der  gute  Kamerad,"  lastly  1 27  words  beginning 
with  K,  twentvtwo  with  P,  two  with  A,  two  with  B,  three  with  Sp,  fifteen 
with  W.) 

Besides  the  purely  outward  connection  of  ideas  by 
similarity  of  sound  there  appears  here  clearly  the  persistence 
in  the  direction  of  the  thought  which  has  once  come  into 
view  [mountain,  huntsman,  cliff,  herdsman,  Vesuvius  and  so 
on]. 

Stereotypy  is  shown  in  the  frequent  recurrence  of  the 
same  turns  of  expression  which  occasionally  are  "done  to 
death."  A  patient  added  on  to  everything ;  "  We  Germans 
don't  have  that,"  another  always  answered,  "  Certainly, 
certainly,"  a  female  patient  invariably  interpolated  "  bitt 
schon."  The  following  passage  is  another  characteristic 
example : — 

"  Ein  venerisches  Feldherrentalent,  ein  venerisches  Arzttalent ;  Sie 
haben  liber  zu  sein,  wenn  ich  will.  Die  Anstalt  ist  ein  renerischcs 
Feldherrentalent  ;  ist  sie  nicht  iiber,  ist  sie  nicht  fiber;  sie  ist  nicht 
renerisch,  iiber  zu  sein  ;  dann  bin  ich  aber  der  L.,  wo  ich  iiber  zu  sein 
bin.  Ich  bin  uber  zu  sein,  was  ich  bin.  Jeder  Anstreicher  ist  hier  am 
Geiste  zu  sprechen.  Sie  kommen  hinausel ;  das  ist  ja  iiber  Esel,  hinausel  I 
Und  da  ist  dieser  renerische  Maler  ;  so  tappig  ist  er  am  Geist  zu  sprechen, 
17-18  Jahre  alt,  iiber  zu  sein,  was  ich  bin.  Kein  verniinftiges  Wort  ist 
iiber  zu  hOren  im  Geist.  Einer  muss  iiber  werden.  Kommt  da  ein  Baron, 
so  ein  Baron,  der  iiber  sein  will  ;  der  is  gar  nicht  iiber.  Der  ist  ja  gar 
nicht  iiber  zu  sein,  was  ich  bin  ;  der  B.  ist  nicht  liber  :  der  ist  eigentlich 
iiber  was  ganz  gefahrlich  iiber  zu  sein.'' 

In  this  .senseless  rigmarole  single  words  and  phrases  are 


PSYCHIC  SYMPTOMS  63 

always  brought  forward  again,  sometimes  exactly  the  same, 
sometimes  with  all  sorts  of  changes,  specially  "  iiber  sein," 
"  venerisch-renerisch,"  "  Arzttalent-Feldherrntalent,"  "  was  ich 
bin,"  "  im  Geist-am  Geist,"  "  hinausel." 

If  stereotypy  is  still  more  strongly  pronounced,  the  morbid 
symptom  of  verbigeration  is  developed,  the  endless  repetition 
of  the  same  sentences,  usually  in  measured  cadence.  A 
female  patient  repeated  the  following  sentence  from  seven 
o'clock  to  half-past  nine  : — 

"  I  beg  you  to  put  me  in  another  bed,  in  the  bed  where  it  was  got 
ready  yesterday  ;  else  I  shall  not  get  out  of  hell  any  more.  Jesus,  dear 
Master  mine,  let  me  rely  faithfully  on  thee  ;  lead  me  in  the  right  path, 
O  do  lead  me  heavenward.  You  are  my  mother's  lady's  maid,  and  my 
mother  is  also  there." 

If  the  endless  repetition  seems  here  to  be  partially  ex- 
plained by  the  form  of  prayer,  the  following  examples  of 
verbigeration  from  the  same  patient  show  distinctly  that  it  is 
a  case  of  monotonous  instinctive  flow  of  speech  :  "  Mutterle, 
fiihr  mich  ums  Kirchlein  herum  bin  um  uns  um  zu  ver- 
futtern,"  "  Zar  mein  Milchen  ums  Eckbrett  in  alle  Zimmer." 
Sometimes  verbigeration  takes  the  form  of  a  senseless  ringing 
of  the  changes  on  a  syllable.  A  patient  connected  the  follow- 
ing with  the  word  "  Bett "  which  was  called  out  to  him  : — 

"Bett,  Bett,  Bett,  dett,  dett,  dett,  ditt,  dutt,  dutt,  daut,  daut,  daut, 
dint,  dint,  dint,  dutt,  dett,  datt.  Wenn  ich  angefangen  habe,  fahre  ich 
fort  bis  zu  Ende."  [When  I  begin,  I  continue  to  the  end.]  "Behindelt, 
bedandelt,  bedundelt,  bedindelt  und  bedandelt,  umgewandelt,  umgedan- 
delt,  umgewandelt,  umgedandelt.  Krone,  krone,  krone,  gekront, 
gekrbnt,  gekront,  gekrant,  gekrant,  gekrant,  beschwant,  beschwant, 
beschwant,  sie  sind  beschwant  und  sind  belohnt,  sie  sind  betont, 
betonen,  betonen,  betonen,  sie  betonen,  sie  belohnen."  "  Es  muss  halt 
so  sein,  wenn  es  herauskommen  soil."  [It  must  just  be  so,  if  it  is  to 
come  out  ]. 

In  writing  also  we  again  find  stereotypy,  it  may  be  in 
frequent  reappearance  of  the  same  expressions  and  phrases, 
or  in  innumerable  slavish  repetitions  of  the  same  strokes  and 
words,  sometimes  with  certain  changes.  Such  an  example 
is  given  in  the  specimen  of  writing  3.  Besides  the  senseless 
persistence  there  is  to  be  noticed  here  the  peculiar  spelling 
("  God  "  instead  of  "  Gott,''  "  Godhatz,"  "  Godwilz,"  "  Godiche 
kannz  nicht  Anders,"  "  Willenz,"  "  Sollenz,"  aber  "  Miissens  "). 
The  specimen  of  writing  2,  as  well  as  Figs.  10,  11,  12,  show 
a  less  obtrusive  stereotypy.  From  the  writing  of  a  patient, 
which  will  be  discussed  later,  consisting  partly  of  senseless 
accumulation  of  syllables,  I  take  the  following  extract  which 
exhibits  the  monotony  of  such  productions  : — 

"  Von  alien  Rocky-Mountygrenzen  ;  in  der  ganzen  Welt  ;  9  Kim. 
(nach  alien  Massen).      Von   alien  Catalonien-grenzen  :   in  der  ganzen 


64 


DEMENTIA  PRECOX 


Welt  :  9  Kim.  (nach  alien  Massen).  Von  alien  Hispanien-Neuspanien- 
San  Juan — in  der  ganzen  Welt  :  Seiten  :  Mittelpunkt  :  Ecken  :  u.  s.  w. 
9  Kim.  (nach  alien  Massen).  Von  alien  San-Salvator ;  in  der  ganzen 
Welt :  (Mittelpunkt  :  Ecken  :  Seiten  :  9  Kim.  nach  alien  Massen)"  usf. 
It  continues  in  the  same  way:  "Von  alien  Mooderfontein,"  "Trans- 
vaal," '*  Zinninseln,"  "Johannesburg,"  "  Gewiirzinseln,"  "Zimmtbaum- 
inseln,"  "  Unter  alien  mit  Gras  bewachsenen  Rainlwschung,''  "  unter 
alien  europiiisch-asiatischen  Kap,"  "  Von  alien  Cappadocien  :  grenzen," 
"  Baotokuten-grenzen,"  "  Kanea-Kretagienzen,"  "  Karfunkel  (Amethist) 
gruben,"  "Kaplandpliitzen,"  "Garibaldis  Ziegeninsel,"  "Unter  alien 
Cottillontanzplatzen,"  "  Panamarepublikgrenzen,"  "  unter  alien  Pana- 
maskandalplatzen,"  "alien  Lumpenfabriken,"  "alien  Minen,"  "Adelaide- 
platzen,"  and  so  on  and  so  on,  invariably  with  the  addition  :  "  i'lberall  in 
der  ganzen  Welt  :  9  Kim.  (nach  alien  Massen)." 

This  senseless  narration  which  endlessly  repeats  the  same 


t^***«>^^ 


(Specimen  of  writing  3.     Stereotopy). 

details  deals  with  the  country  which  it  is  "  self-evident "  the 
patient  lays  claim  to  for  himself  and  his  children. 

Negativism  shows  itself  in  the  domain  of  speech 
activity,  on  the  one  hand  in  mutism,  on  the  other  hand  in 
resistive  or  evasive  ansivers.  Many  patients  answer  every 
question  with  another  question  or  with  "  How  ? "  and  then 
perhaps  without  further  ado  give  the  required  information  ; 
others  simply  repeat  the  question.  Answers  are  often  given 
that  say  nothing,  are  indefinite,  or  quite  without  relation  to 


PSYCHIC  SYMPTOMS  6$ 

the  subject.  Negativism  appears  more  distinctly  when  the 
patients  answer  to  all  remarks,  "  I  don't  know  "  or  "  I  don't 
need  to  tell  you  that."  "  You  know  that  yourself  already,"  a 
patient  constantly  answered,  "  I  know  everything,  oui,  oui." 
It  frequently  comes  to  "  speaking  past  the  subject."  To 
the  question  always  repeated;  "How  are  you?"  a  patient 
replied  in  succession,  "  On  the  bridge,"  then  "  Mustardseed," 
next  "  Prayer-book,"  lastly,  "  Not  at  all  ;  I  am  sitting." 

Sometimes  the  patients  obstinately  maintain  silence,  as 
long  as  one  is  occupied  with  them,  and  begin  to  talk  when 
one  turns  away  from  them,  or  they  try  to  speak,  utter  a  few 
words,  but  suddenly  break  off  and  cannot  be  moved  to  any 
further  utterance ;  a  few  patients  speak  with  certain  people, 
but  are  wholly  inaccessible  to  others.  Many  patients  speak 
low,  scarcely  move  their  lips,  murmur  unintelligibly  to  them- 
selves. In  the  end  it  comes  to  complete  mutism,  which  lasts 
for  months  or  years,  but  which  may  be  suddenly  interrupted 
by  outbursts  of  the  most  violent  abuse  or  screaming.  In 
certain  circumstances  the  patients  in  this  state  still  give 
utterance  in  writing  to  their  thoughts,  sometimes  expressing 
them  comprehensively  and  for  the  most  part  very  confusedly  ; 
a  patient  declared  that  he  wrote  because  he  could  not  find 
words  readily.  As  a  rule,  however,  expression  in  writing  is 
also  suppressed  by  negativism.  The  patients  cannot  be 
persuaded  to  write  at  all,  or  they  break  off  after  a  few  letters, 
go  playing  over  the  paper,  only  scrawl  a  few  unintelligible 
flourishes,  or  tap  with  the  pencil  on  the  desk  keeping  time. 
In  measurements  of  pressure  in  writing  one  sees  sometimes  a 
continuous  fall  of  pressure  which  is  to  be  accounted  for  either 
by  a  simple  failure  of  will-tension  or  by  negativistic  disorder. 
A  patient  wrote  Roman  mirror  writing  in  order  that  no  one 
might  be  able  to  read  it. 

Linguistic  movements  of  expression  also  seem  to  the 
patients  to  be  often  under  the  power  of  external  forces.  We 
have  already  stated  above,  that  many  patients  are  forced  not 
only  to  think  but  also  to  say  aloud  what  is  suggested  to  them. 
Others  "must"  scream,  "rage  and  abuse,"  call  out  suddenly 
"  Halleluia,"  "  Pfui  "  or  "  Kaiser  and  King  "  ;  a  patient  "  was 
obliged"  involuntarily  to  "speak  Bambergerisch."  In  the 
same  way  the  patients  sometimes  cannot  answer  because 
the  voices  have  forbidden  them. 

Derailments  in  linguistic  expression  form  a  specially 
important  domain  in  the  speech  disorders  of  dementia 
praecox.  Vocal  speech  itself  can  be  changed  in  the  most 
varied  way  by  side  and  cross  impulses.  The  patients  in 
speaking,  bellow,  screech,  murmur  or  whisper,  scarcely  move 

E 


66  DEMENTIA  PR/ECOX 

their  lips,  keep  their  teeth  closed,  or  often  pass  suddenly  from 
low  whispering  to  loud  screaming.  The  flow  of  speech  is 
frequently  hurried  and  rapid  even  in  low  speaking,  sor^etimes 
varying  quite  irregularly,  or  speech  is  jerkily  broken  up, 
or  produced  keeping  time  with  sharp  rhythmical  modulation. 
The  cadence  often  lacks  the  risings  and  fallings,  the  melodies 
of  speech  ;  the  timbre  of  the  voice  may  also  be  changed. 
The  patients  speak  in  falsetto,  through  their  noses,  in  an 
artificial  bass  voice,  pass  suddenly  from  one  key  to  another. 
Mignot  rightly  calls  attention  to  the  fact  that  the  changes  in 
strength  of  tone,  height  of  tone,  rapidity  and  rhythm  in  our 
patients  are  throughout  lacking  in  that  close  relation  to 
thought  and  mood,  which  in  healthy  people  makes  the  voice 
such  a  pliant  means  of  expression  of  inward  states ;  the 
individual  peculiarities  of  vocal  speech  are  changed  without 
relation  to  each  other  or  to  the  psychic  occurrences  by  which 
they  are  usually  ruled. 

Later  there  are  introduced  into  speech  not  infreqyently 
clicking  and  smacking  sounds,  sniffing,  and  snorting,  bleating 
words  without  sense,  stock  phrases  with  tiring  repetition. 
Many  patients  speak  affectedly  with  excessively  distinct 
pronunciation,  with  distortion  of  single  letters  and  with 
senseless  intonation  ;  others  of  set  purpose"  in  a  childishly 
awkward  manner,  deliberately  careless,  indistinct,  limp,  or 
in  the  rudest  dialect ;  others  again  join  on  diminutives  or 
other  capricious  additions,  and  still  others  speak  in  an 
unctuous  preacher's  tone.  A  patient  mutilated  and  distorted 
the  words,  said  "glank"'  for  "krank,"  "  nuten  Hag"  for 
"guten  Tag,""  Feinbeg"  for  "Heidelberg,"  spoke  of  the 
"Soktor"  (Doktor)  "Notessor"  (Professor).  Many  patients 
answer  singing;  a  female  patient  sang  her  own  conversation 
and  answers. 

In  their  zuritings  there  is  found  an  arbitrary,  peculiar 
disorder  with  whimsical  misuse  of  punctuation  marks  and 
orthography  invented  by  themselves.  The  letters  show  for 
the  most  part  a  very  changing  character,  are  sometimes 
large,  and  pretentious,  sometimes  small  and  scrawling,  some- 
times irregular,  slapdash  or  punctiliously  uniform,  as  the 
specimens  of  writing  given  above  show.  Many  patients 
write  mirror-writing.  Gregor  found  in  his  enquiries  slowing 
of  writing.  The  writing  pressure  also  shows  many  oscillations. 
Gross  was  able  to  establish  at  one  time  very  high,  at  another 
time  very  low  pressure  values,  also  lengthening  of  the  pauses, 
and  lastly  extraordinarily  great  fluctuation  of  all  value?,  even 
in  quite  short  periods  of  time,  a  sign  of  great  fluctuation  in  the 
attention  and  volition  of  our  patients. 


PSYCHIC  SYMPTOMS  67 

Internal  Speech. — But  much  more  significant  are  the 
disorders  of  internal  speech,  of  the  transformation  of  ideas 
into  Hnguistic  movements  of  expression.  The  consideration 
of  the  disorders  of  speech  in  dreams  has  shown  that  the 
variety  of  such  errors  is  very  great.  Unfortunately  in 
dementia  prsecox  there  have  not  been  as  yet  any  satisfactory 
enquiries  into  the  corresponding  phenomena ;  nevertheless  it 
seems  to  me  that  we  find  here  the  most  important  of  the 
anomalies  .observed  there  with  surprising  similarity.  Certainly 
the  difficulty  of  the  interpretation  is  greater  here,  as  we, 
unlike  the  experience  of  dreams,  can  seldom  ascertain  what 
the  patient  has  exactly  wished  to  say. 

Paraphasia. — We  shall  have  to  keep  apart  two  chief  forms 
of  paraphasic  disorders;  ^xs\\y ,  derailments  in  finding  words , 
secondly,  disorders  in  connected  speech.  In  the  first  group 
there  may  be,  to  begin  with,  a  simple  mutilation,  a  change 
or  partial  fusion  of  words  in  common  use.  A  patient  said  : 
"  Ich  scham  "  instead  of  "  Ich  shame  mich  "  ;  another  com- 
plained that  he  was  "  schmerzend,  schadigt  and  genotigt " ; 
another  spoke  of  "  Reglierung."  "  Das  Herz  ist  schwankig," 
"  hilfbar "  instead  of  hilfsbereit,"  "  Zaubrigkeiten  "  instead 
of  "  Zauberei,"  "direktiv"  ("I  can't  pronounce  anything") 
instead  of  "  direkt "  are  examples  of  word-transformations, 
A  patient  spoke  of  the  "  Wundneiarzt,"  when  he  was  evidently 
bringing  together  "Wundarzt"  and  "Arznei";  another  felt 
himself  "  kopfbewusstlos,'"  "  unbewusstlos." 

Another  occurrence  which  is  frequent  in  dreams,  the 
substitution  of  one  word  for  another  usually  similar  in  sonnd 
or  meanings  an  occurrence  which  plays  a  large  part  in  ordinary 
paraphasia  also,  is  difficult  to  trace  in  our  patients  since  the 
meaning  of  such  utterances  is  mostly  unrecognisable.  But 
we  may  well  suppose  that  many  of  the  unintelligible 
expressions  of  the  patients  arise  by  paraphasic  word- 
substitution,  •  They  speak  of  the  "  Totenwahn,"  of  the 
"  Mondteufel,"  of  the  "  Dolchmesser  mit  Hochzeitszettel," 
of  the  *'  sozialdemokratischen  Jagdstock,"  of  the  "  souveranen 
Neuner,"  "  Papstneuner."  A  patient  worked  "  mit  dem 
Vernunftgott "  ;  one  felt  himself  "  gaumenschwach "  ;  to 
another  something  appeared  "  schwarzwalderisch  " ;  a  fourth 
declared,  "  Ihr  seid  Unterwalder";  a  fifth  called  the  physicians 
"  Falschzugeschworene  "  ;  a  sixth  said  that  a  "  Wecker  vom 
Kriegsgericht "  had  been  there  ;  a  female  patient  complained 
that  someone  was  pulling  the  "  Frevelschnur."  A  male 
patient  complained  that  his  senses  were  "  checked  "  ;  "  The 
doctor  has  collected  my  four  senses." 

Neologisms. — There  are  intimations  here  already  of  a 


68  DEMENTIA  PR/ECOX 

further  form  of  paraphasia  cleraihnent,  which  may  become  of 
very  great  extent  in  dementia  pn-ecox,  neologisms.  In 
several  of  the  examples  quoted  it  \Veis  already  a  case  of  new 
unintelligible  words,  but  they  were,  however,  composed  of 
sensible  component  parts.  ("  Papstneuner,"  "gaumenschwach," 
"  PVevelschnur ".)  But  there  may  be  produced  also  quite 
senseless  collections  of  syllables,  here  and  there  still  having 
a  sound  reminiscent  of  real  words.  A  patient  spoke  of  the 
'  Gestiibe  und  Angstbetrieb  "  ;  another  of  the  "  Totendumpf " ; 
a  third  of  the  "Lebepuppe";  a  fourth  of  the  "  Oxypathie," 
from  which  he  was  suffering  ;  a  fifth  was  "  krikeliert"  ;  a  sixth 
did  not  want  to  belong  "  zur  Tatowie  " ;  a  seventh  drivelled 
in  an  unintelligible  way  of  "  Reichsleben  und  Gerichtsleben.'* 
A  female  patient  obstinately  demanded  "  ihre  Scheidung,. 
ihr  Amtsgericht,  ihr  Jahr  1888,  ihre  Sallesichten  und  Sara- 
sichten  "  ;  another  complained  about  the  "  Physizieren  und 
Mechanisieren,"  by  which  she  without  doubt  wished  to 
indicate  sexual  molestation.  Many  neologisms  may,  as 
happens  in  dreams,  be  expressions  of  more  complicated  or 
morbid  ideas,  for  which  no  words  exist.  Formations  such 
as  "  Aquinoktialhimmelskonigskind,"  "  Wasserpadagogium," 
"  Bombardongehiir,"  "  Verkiirperungsunternehmen  "  make  such 
a  supposition  probable.  A  patient  explained  that  he  would 
travel  to  Constantinople  "auf  dem  Luftkompressionswege  "  ; 
another  had  "  bengalische  Gehirnerweichung  durch  Simulan- 
tenbehandlung" ;  a  female  patient  spoke  of  the  "Glieder- 
auswachsung,"  and  the  "  Blutvergiftungswas.ser." 

The  tendency  to  silly  plays  on  words  and  neologisms 
can  get  the  upper  hand  in  our  patients  to  such  an  extent, 
that  they  fall  into  a  wholly  incomprehensible  gibberish ;  they 
usually  then  give  it  out  as  a  foreign  language  which  by  slight 
changes  in  the  syllables  may  be  changed  into  any  other  you 
like.  A  patient  gave  as  his  first  name,  "  Detscheneinaninad- 
renn."  Another  called  himself,  "Jesasus  Christasusasus 
Heilandasus "  and  wrote  down  as  his  address  "  Aewa  owa 
Ouwou  Aewouwio  sanco  to  totosaak  saakiou  sahaia  siri  tou 
toutou,  Hoch  Waiowauoxyowiiiowaiioxyoohoeho  hachi  hihi  "  ; 
it  was  the  name  of  his  castle.  Another  example  is  given  in 
the  following  fragment  from  a  petition  to  the  district  court 
which  began  at  first  quite  sensibly  : — 

"Urrass  Asia  peru  arull  ptlluss  Pisa  anueil  pelli. 

"  Madrass  ihsa  Peru  parell  mull  illuss  thesu  thariass  inehluss  pinta 
aperu  ailesa,  medut  prusa  exel  ill  Farrawall. 

"  Cap  Nansen  ell  Pisa  uruhl  nell  palle  ixo  piso  panthe  alluss  pesass 
esu  lull  maxima  perrett  ill  panse  arruse  ill  perrell  Thatciduss  usa  ihru 
maltell  pe  uxa  thyrra,  pia  apenlia  ruhsa  iss  tlietu,  cralluss  Asia  peni  vendi 
arrull,  mesa.     Uss  Adda  pia  mellu  Exter  a  probro  ;   Mess  Killian  esu 


PSYCHIC  SYMPTOMS  69 

panein  Dante,  illo  pisa  thesu  arrendt,  mess  pasi  Ural  pill  palli  mesa  essu 
Acus  Cantone,  cU  Albydill,  Anscliill,  Kulla  Apia  Nestor,"  and  so  on. 

In  this  senseless  collection  of  syllables  there  are  scattered 
a  number  of  correct  or  somewhat  altered  proper  names 
("  Asia,"  "  Pisa,"  "  Madrass,"  Peru,  Nansen,  Adda,  Exter, 
Killian,  Dante,  Ural,  Apia,  Nestor,  Farrawell,  Thatciduss, 
Albydill) ;  some  (Pisa,  Asia)  appear  again,  as  also  a  series  of 
other  newly  formed  words  (arull,  perell,  ill,  thesu,  mesa,  esu, 
pia).  There  are  also  innumerable  similarities  of  sound 
(pellus-pelli-pill-palli,  mehluss-alluss-cralluss,  arull-uruhl- 
arruse-ruhsa,  peru-perell-perett,  pinta-panthe-apentia-peni- 
penem-pasi),  though  not  in  unbroken  sequence,  but  like  the 
repetitions  scattered  irregularly  thoughout  the  whole  series. 
If  the  whole  comprehensive  piece  of  writing  had  been 
reproduced,  that  would  have  been  still  much  more  distinct.  An 
inner  connection  is  only  recognisable  in  so  far  as  the  names 
introduced  all  apply  to  towns,  countries  or  persons  ;  in  Farewell 
("  P^arrewell ")  and  Cap  Nansen  there  could  also  perhaps 
be  found  a  still  nearer  relation.  The  patient  interrupted  his 
gibberish  with  the  remark,  "  Now  again  to  the  subject "  and 
then  writes  of  his  "discoveries,"  among  which  a  great  number 
of  countries  are  mentioned;  he  concludes  with  more  gibberish 
as  above.  In  the  middle  sentence  there  is  the  following 
silly  play  on  words  ;  "  Puntas  :  Punte  :  Punto  :  Punti :  Punta  : 
Puntes :  Puntal :  Puntales  :  Puntu  :  Punto :  Puntel  :  Puntelus." 

Sometimes  it  comes  to  senseless  rhyming  as  in  the 
following  transcript : — 

"Sei  ruhig,  ich  werde  ein  lichter  Trager  mit  seiner  dummes  Zeug 
Klager — er  fetter  schon  die  Arm  im  Schnauzen  mit  seiner  gimmen 
guten  Bauzen.  Er  hat  nicht  schlucken  voll  Erbarmen  aus  voller 
Schmerz  in  seiner  Karmen — Von  Lichter  schlagt  er  mir  die  Lichter  in 
Donnerwetter  HoUenrichter,  ein  Donnerwetterrichter,  ein  schwarzer 
Seljon  ein  Secht  in  meine  Hinterlader  spricht  einst  ein  junger  halb  in 
Krater.  Ein  Vater  Himmel  Donnerwetter  Licht — ich  lade  alle  Teufel 
aus  und  trug  die  HoUenmarke  naus." 

This  wholly  incomprehensible  talk  made  up  of  neologisms, 
similarities  of  sound,  rhymes  and  repetitions  brings  to  mind 
the  speech  of  dreams  as  also  the  reading  of  a  delirious 
alcoholic  from  a  blank  page.  We  find  the  same  thing  again 
in  the  next  piece  of  writing: — 

"Weiss  blau  bin  ich  gnau  soh  der  Pfau.  Weiss  und  gelb  soh  die 
Quell.  Schwarz  und  weiss  soh  das  Eis.  Rot  und  schwarz  soh  der  Bass 
und  soh  das  Fass.  Weiss  wieh  Schnee  rot  im  Kleeh  soh  die  Hoh  oh 
welches  Gliick.  Miiuschen  grau  rot  und  grau  rot  und  blau.  Wenn 
und  wann  soh  die  Tann.  Holz  zum  Kranz  soh  der  Tann.  Mauschen 
gleih  soh  das  Blau." 

Almost  still  more  peculiar  do  the  lyric  poems  appear  to 


70  DEMENTIA  PR.4£COX 

us,  which  a  female  patient  composed  in  a  language  invented 
by  herself,  though  usually  she  could  express  herself  without 
difficulty.     I  give  one  verse  here  : — 

Stanzuru  vimmt  den  Bark  zum  Obendrob 
Heuschend  lagert  ein  Bigart  im  Striehen  Obss 
Leulend,  lagcrnd,  bimmt  die  Bimbii  im  Hyurisch 
Bordent  blickt  Aug  iin  Drugsag  des  Auggehoks 
Rastand  blickt  die  Staniza  im  Herz  eingelallt 
Schwiichend  irit  Corpus  im  trausen  Laufgedalt 
Zu  einein  armen  kranken  Cornt  von  Erdgedob. 

A  few  words  ("Bark,"  "lagert,"  "blickt,"  "Aug," 
"  rastend,"  "  Herz,"  and  so  on)  are  still  intelligible,  but  for 
the  most  part  it  is  a  case  of  wholly  senseless  neologisms. 
At  the  same  time  a  certain  tendency  to  assonance  and  a 
childish  playing  with  sounds  cannot  be  lost  sight  of 
("vimmt — bimmt — Bimbii."  "Obendrob — Erdgedob,"  "Stan- 
zuru—  Staniza,"  "Aug  —  Auggehoks,"  "Corpus  —  Cornt," 
eingelallt, — gedallt,""  heuschend — leulend — lagernd — bordent, 
— rastend — schwachend  "). 

Akataphasia. — Not  less  worthy  of  note  than  the  disorders 
in  word-finding  are  those  which  influence  in  a  morbid  way 
the  form  of  speech.  At  first  we  have  to  do  with  those 
derailments  in  the  expression  of  thought  in  speech  which  we 
call  akataphasia.  In  this  case  the  patients  either  do  not  find 
the  expression  appropriate  to  their  thoughts,  but  only 
produce  something  with  a  similar  sound  ("displacement 
paralogia"),  or  they  let  their  speech  fall  into  quite  another 
channel  ("derailment  paralogia"),  A  patient  said  he  was 
"wholly  without  head  on  the  date  "for  "he  did  not  know 
the  date " ;  another  complained  he  "  lived  under  protected 
police"  instead  of  "under  the  protection  of  police"  a  third 
declared  to  his  father  he  "  was  the  greatest  judicial  murder" 
instead  of  "  on  him  the  greatest  judicial  murder  was  practised," 
Similarly  a  patient  remarked  he  was  "the  disguise  in  all 
ways "  instead  of  "  he  had  disguised  himself  in  all  ways." 
Another  patient  said  he  had  "his  fiancee  always  in  speech" 
instead  of  "  his  fiancee  still  continued  to  speak  to  him " 
(through  voices)  ;  a  female  patient  asserted  she  knew  "  in  a 
miracle"  that  her  father  w^s  a  priest  instead  of  'she  had 
learned  it  in  a  miraculous  way. '  To  this  series  also  the 
expression  of  a  patient  mentioned  before  belongs,  he  "  toned 
with  God,"  instead  of  "he  heard  tones  from  God."  and  the 
utterance  of  another  that  he  "  was  instructed  in  the  experi- 
mentally approved  specialty." 

The  following  utterances  give  us  ground  for  concluding 
that  the  expression  of  thought  in  speech  glides  off  into  side- 
ideas    which    intrude    themselves ;    "  I    have    a    suspended 


PSYCHIC  SYMPTOMS  71 

appetite,"  "  I  have  voluntary  disease  of  the  eyes,"  "  They 
are  threaded  at  the  head,"  "  I  am  national-Hberal  chased 
away."  A  patient  said  that  he  had  danced,  "  lay  in  morti- 
fication." To  this  group  should  perhaps  be  reckoned  some 
of  the  bevvilderingly  nonsensical  utterances,  which  were 
quoted  above  as  examples  of  the  incoherence  of  speech  of  our 
patients,  and  which  apparently  represent  a  sen.seless  jingling 
of  words.  A  patient  used  the  word  "Log"  a  great  deal 
and  explained  that  it  was  shortened  from  "  logic,"  and  then 
leaving  the  track  he  continued  "  Lot-overlog-underlog ;  philo- 
logists have  outlived  themselves ;  these  are  individual 
expressions."  Here  the  relation  to  childish  playing  with 
sounds  is  distinct. 

Construction  of  Sentences. — A  further  form  cf  impair- 
ment of  speech  springs  from  disorder  in  the  construction  of 
sentences.  In  the  examples  of  incoherence  of  the  train  of 
thought  which  were  given  before,  the  syntax  is  also  confused 
in  different  places  ("  Former  service  and  then  she  does  it," 
"  I,  and  that  is  also  so  curious,  therefore  the  nun."  "  I  should 
come  from  M.  because  always  something  happens,  leg  broken 
or  something,  they  have  quarrelled,"  "as  I  that  at  last  of 
those  that  particularly  believe").  A  patient  wrote  in  an 
anonymous  letter,  "  Mortimer  in  reference  to  two  kings "  ; 
another  said  he  was  sad  "on  account  of  the  national  economic 
interests,  concerning  foreign  commerce."  In  more  pro- 
nounced disorder  speech  may  develop  into  the  style  of  a 
telegram,  doing  without  all  superfluous  phrases,  and  in  the 
end  there  may  be  complete  disappearance  of  sentence- 
formation.  An  example  of  this  is  given  in  the  following 
petition  to  the  chief  of  the  police  which  is  called  "  Cabinet 
affair  honesty  "  : — 

"  By  the  grace  of  God  are  the  Emperor  of  the  present  analogy 
of  the  spirit  'in  spiritu'  of  radical  sworn  upon  oath  subjects  of  proved 
alarm-satisfaction  of  my  stamped  masculine  disposition 'centre  Calvin ' 
of  academic  birth-stamp  of  analogy  of  party  liable  to  military  service 
of  declarative  property  customary  of  honest  palatinate  despotism  of  the 
highest  of  all  honesty  'contrary  disposition'  of  freely  intelligently 
right  of  acquisition  of  foreign  rank  of  financial-joint  legal  contract  of 
psychiatric  truth  of  forgotten  wound-fever  of  frugally  imperial  bureaucracy 
of  secured-capital  profitable  persecution  of  the  Christians  most  obediently 
S,,  imperial  parliamentary  IV.  service-laced  prize-seal.  Affair  of  an 
oath  I     Radical 'brevi  manu '!  " 

In  this  singular  piece  of  writing  besides  the  verb  "sind" 
only  dependent  genitives  are  found  as  the  one  indication  of 
syntax.  For  the  rest  it  swarms  with  newly-formed  compound 
words,  the  parts  of  which  in  themselves  are  rational  (Geistes- 
analogie,"    "  radikaleidlich,"    "  Alarmgenugtuung,"    "  meinge- 


72  DEMENTIA   PR/FXOX 

stempelt,"  and  so  on).  "  Geistesanaloijie "  is  soon  followed 
by  "  Parteianalogie,"  "  meingestempeit "  by  "  Geburtsstempel," 
•'  Mannesgesinnung  "  by  "  Gegengesinnung."  "  radikaleidlich  " 
by  "  Eidessache "  as  indication  of  the  persistence  which  is 
invariably  noticeable  in  such  documents.  "  Dienstgeschnurte 
Prisensiegel "  might  be  regarded  as  displacement  paralogia 
("  Dienstsiegel ").  The  whole  is  a  sample  of  confusion  of 
speech  in  which  moreover,  in  spite  of  complete  want  of 
connection,  there  is  still  a  certain  general  colouring  of  the 
ideas  recognisable. 

Train  of  Thought. — The  last  group  of  examples  brings 
us  to  derailments  in  the  train  of  thought  itself,  which 
certainly  often  accompany  the  forms  hitherto  discussed. 
As  already  mentioned,  we  hear  from  our  patients  a  great 
many  quite  imcomprehensible  and  disconnected  utterances, 
in  which  it  can  scarcely  be  only  a  question  of  disorders  of 
linguistic  expression,  even  though  it  is  impossible  in  the 
individual  case  to  discover  the  inner  mechanism  by  which 
the  utterances  arose.  Thus  a  patient  spoke  of  the  "  brain- 
navel  of  the  merchants'  association  "  ;  another  said,  •'  One 
cannot  take  the  direction  from  the  reflection."  But  some- 
times a  derivation  of  the  train  of  thought  from  the  scries  of 
ideas  which  is  immediately  present,  to  another,  as  frequently 
happens  in  dreams,  is  clearly  seen.  A  patient  when  asked 
what  year  it  was,  replied,  "  It  may  be  Australia,"  wandering 
from  the  series  of  years  to  the  series  of  continents ;  another 
to  the  question  what  month  it  was,  answered  Strassburg.  A 
third  complained  that  the  attendant  had  "  forced  the  tax- 
duty "  on  him,  and  .so  passed  from  the  idea  of  some  sort  of 
unpleasant  influence  to  that  of  paying  taxes.  Perhaps  the 
utterance  of  defence  made  by  a  patient  "  Get  away  from  the 
reins "  is  to  be  regarded  in  a  similar  way,  in  as  far  as  the 
approach  of  anyone  awakened  the  idea  of  the  putting  on  of 
reins.  When  a  patient  said,  "  Suffering  hunger  is  stronger 
than  in  all  deaf-mutes,"  the  supposition  may  be  made  that 
here  the  idea  of  deaf-mutes  has  taken  the  place  of  a  more 
general  thought  comprehending  want  or  misfortune.  Also 
the  saying,  "  I  have  gone  through  much  for  the  German 
language,"  may  be  considered  as  a  derivation  of  the  train  of 
thought,  as  also  the  expression  relating  to  some  or  other 
indifferent  occurrence  ;  "  That  can  be  written  with  blue  ink." 

One  will  scarcly  go  wrong  if  one  assumes  a  derivation  in 
those  forms  of  talking  past  a  subject,  in  which  a  negativistic 
evasion  of  the  right  answer  is  not  clear.  A  patient  replied 
to  the  question  in  which  town  the  hospital  was  by  .saying, 
"  The  house  stands  in  the  gospel  of  Luke  of  the  eighth,  and 


PSYCHIC  SYMPTOMS  73 

if  one  has  swine,  one  can  slaughter  them."  [German  .  .  . 
des  achten  .  .  .  schlachten.]  Here  after  the  first  derivation 
of  the  train  of  thought  to  another  domain  of  ideas  another 
follows  which  is  conditioned  by  the  rhyme.  The  same 
patient  on  being  asked  to  enumerate  the  names  of  the 
months,  did  so  in  the  following  manner :  "  Jas  je  ji  jo  jan  jan 
dran  drin  draus  dann  Mainz,  dann  Worms."  He  first  fell 
into  the  vowel  series,  then  into  similarities  of  sound  and  into 
practised  combinations  of  letters  ("  drin-draus "),  and  lastly, 
into  the  enumeration  of  names  of  towns. 

From  these  disorders  the  transition  is  easy  to  those 
pnenomena  with  which  we  became  acquainted  before  as 
speaking  past  a  subject.  Here  it  is  no  longer  the  transference 
to  expression  in  speech  that  is  morbidly  influenced,  but  the 
ideas  aroused  by  the  circumstances  are  themselves  already  in 
their  origin  pushed  aside  or  suppressed  by  ideas  related  but 
lying  remote  or  opposed  to  the  original  ones. 


CHAPTER    III. 

GENERAL  PSYCHIC    CLINICAL  PICTURE 

Now  if  we  make  a  general  survey  of  the  psychic  clinical 
picture  of  dementia  pr.tcox,  as  it  has  presented  itself  to  us 
in  the  consideration  of  about  a  thousand  c'ases  which  belong 
to  the  subject,  there  are  apparently  two  principal  groups  of 
disorders  which  characterise  the  malady.  On  the  one  hand 
we  observe  a  iveakening  of  those  emotional  activities  ivliich 
pennanently  form  the  mainsprings  of  volition.  In  connection 
with  this,  mental  activity  and  instinct  for  occupation  become 
mute.  The  result  of  this  part  of  the  morbid  process  is 
emotional  dulness,  failure  of  mental  activities,  loss  of  mastery 
over  volition,  of  endeavour,  and  of  ability  for  independent 
action.  The  essence  of  personality  is  thereby  destroyed,  the 
best  and  most  precious  part  of  its  being,  as  Griesinger  once 
expressed  it,  torn  from  her.  With  the  annihilation  of 
personal  will,  the  possibility  of  further  development  is  lost, 
which  is  dependent  wholly  on  the  activity  of  volition.  What 
remains  is  principally  what  has  been  previously  learned  in 
the  domain  of  knowledge  and  practical  work.  But  this  also 
sooner  or  later  goes  to  ruin  unless  the  failing  inner  main- 
spring is  replaced  by  outer  stimulus  which  rouses  to  continual 
practice  and  so  obviates  the  slow  disappearance  of  ability. 
Whether  and  how  far  the  malady  directly  injures  the  mental 
faculties  apart  from  their  gradual  disappearance  through  disuse 
of  mental  function  needs  further  inquiry.  The  rapidity  with 
which  deep-seated  and  permanent  dementia  sometimes 
develops  in  the  domain  of  intellectual  work  makes  the 
suggestion  easy,  that  it  also  may  itself  be  drawn  by  the  disease 
into  a  sympathetic  morbid  state,  even  though  it  is  invariably 
encroached  on  to  a  much  less  degree  than  emotion  and 
volition.  It  is  worthy  of  note  in  any  case,  that  memory 
and  acquired  mental  proficiency  may  occasionally  be 
preserved  in  a  surprising  way  when  there  is  complete  and 
final  destruction  of  the  personality  itself. 

The  second  group  of  disorders,  which  gives  dementia 
prsecox  its  peculiar  stamp,  has  been  examined  in  detail 
especially  by  Stransky.^     It  consists  in  the  loss  of  the  inner 

'  StTiinksy.  Jahrb.  f.  Psychiairie,  xxiv.,  1903,  i  ;  Wiener  nied.  I'resse  1905,  28. 


GENERAL  CLINICAL  PICTURE  75 

unity  of  the  activities  of  intellect,  emotion,  and  volition  in 
themselves  and  among  one  another.  Stransky  speaks  of  an 
annihilation  of  the  "  intrapsychic  co-ordination,"  which  is 
said  to  loosen  or  destroy  the  articulations  of  the  "  noopsyche  " 
and  the  "  thymopsyche "  themselves  as  well  as  their  mutual 
relations.  This  annihilation  presents  itself  to  us  in  the 
disorders  of  association  described  by  Bleuler,  in  incoherence 
of  the  train  of  thought,  in  the  sharp  change  of  moods  as  well 
as  in  desultoriness  and  derailments  in  practical  work.  But 
further  the  near  connection  between  thinking  and  feeling, 
between  deliberation  and  emotional  activity  on  the  one 
hand,  and  practical  work  on  the  other  is  more  or  less  lost. 
Emotions  do  not  correspond  to  ideas.  The  patients  laugh 
and  weep  without  recognisable  cause,  without  any  relation  to 
their  circumstances  and  their  experiences,  smile  while  they 
narrate  the  tale  of  their  attempts  at  suicide :  they  are  very 
much  pleased  that  they  "chatter  so  foolishly,"  and  must 
remain  permanently  in  the  institution ;  on  the  most  in- 
significant occasions  they  fall  into  violent  terror  or  outbursts 
of  rage,  and  then  immediately  break  out  into  a  neighing 
laugh.  It  is  just  this  disagreement  between  idea  and 
emotion  that  gives  their  behaviour  the  stamp  of  "  silliness." 
Stransky  traces  the  soiling  of  the  bed  also  to  a  morbid 
connection  of  this  procedure  with  feelings  of  pleasure. 

The  work  of  the  patients  is  not  as  in  healthy  people  the 
expression  of  their  view  of  life  and  temperament,  it  is  not 
guided  by  the  elaboration  of  perceptions,  by  deliberation  and 
moods,  but  it  is  the  incalculable  result  of  chance  external 
influences,  and  of  impulses,  cross  impulses,  and  contrary 
impulses,  arising  similarly  by  chance  internally.  A  patient 
sang  as  he  jumped  into  the  Neckar ;  others  burn  or  scatter 
their  money,  try  to  cut  the  throat  of  a  beloved  child,  or  with 
pitiful  screaming  maltreat  themselves  in  the  most  regardless 
way.  The  phenomena  of  paramimia  belong  to  this  group  also, 
the  side  activities,  as  well  as  the  oddities  which  result  from 
them,  but  especially  do  the  disorders  of  inner  speech  find 
their  place  here,  which  may  likewise  be  understood  from  the 
point  of  view  of  a  relaxation  of  the  relations  between  idea  and 
actual  speech.  By  this  destruction  of  inner  concatenation  and 
causation  the  whole  of  active  life  receives  the  stamp  of  the 
incalculable,  the  incomprehensible,  and  the  distorted. 

As  it  seems  to  me,  there  exists  an  inner  connection  between 
the  two  groups  of  disorders,  which  are  here  distinguished. 
What  fashions  our  experiences  into  a  firmly  mortised 
building,  in  which  each  part  must  fit  the  other  and  sub- 
ordinate itself  to  the  general  plan,  are  general  conceptions 


76  DEMENTIA  PR^ECOX 

and  ideas.  The  even  calm  of  our  temper,  the  swift  victory 
over  sudden  shocks,  are  guaranteed  by  the  higher  general 
emotions  ;  on  the  one  hand  they  work  by  acting  as  a  check, 
and  on  the  other  hand  they  give  to  the  background  of  our 
mood  a  definite  colouring  even  when  no  emotional  stimuli 
are  caused  by  special  internal  or  external  experiences. 
Lastly,  the  inner  unity  of  our  will  is  conditioned  by  the 
general  trend  of  volition  which  is  always  alive  in  us,  and 
w  hich  is  the  product  of  our  racial  and  personal  development. 
We  may  therefore  expect  that  a  weakening  or  annihilation 
of  the  influence  which  general  conceptions,  higher  emotions, 
and  the  permanent  general  trend  of  volition  exercise  on  our 
thinking,  feeling,  and  acting,  must  draw  after  it  that  inner 
disintegration,  those  "  schizophrenic "  disorders,  which  we 
meet  with  in  dementia  pra^cox.  It  seems  to  me  that  the 
disorders  observed  in  the  patients  and  the  complaints  to 
which  they  give  utterance,  point  exactly  to  injury  to  the 
general  scheme  of  our  psychic  development,  as  it  fixes  the 
substance  of  our  personality.  The  general  trend  of  volition 
and  also  the  higher  emotions  might  form  the  first  point  of 
attack.  But  further  the  instrument  of  general  conceptions 
with  its  regulating  influence  on  the  train  of  thought  would 
then  also  become  worthless,  if  the  will  were  no  longer  capable 
of  using  it.  Weygandt  speaks,  obviously  following  a  similar 
line  of  thought,  of  an  "  apperceptive  dementia  "  in  as  far  as 
the  injured  "  active  apperception  "  signifies  the  dominion  of 
volition  over  the  formation  and  the  course  of  psychic 
processes. 


CHAPTER    IV. 
BODILY  SYMPTOMS. 

Besides  the  psychic  disorders  there  are  also  in  the 
physical  domain^  a  series  of  morbid  phenomena  to  record, 
whose  more  exact  relations  to  the  fundamental  malady  are 
not  yet,  it  must  be  admitted,  proved  in  all  points. 

Headaches  are  frequent,  to  which  Tomaschny  has 
specially  directed  attention  ;  they  are  referred  to  forehead 
and  temples,  but  also  to  the  vertex  or  the  occiput,  mostly  in 
the  form  of  oppression,  a  pressing  together.  To  these  may  be 
added  unpleasant  sensations  of  all  kinds  in  the  most  different 
parts  of  the  body,  of  which  we  have  to  a  certain  extent  made 
mention  already,  also  those  irritative  phenomena  which  are 
so  frequently  present  in  the  higher  mechanisms  of  sense. 
Sensitiveness  to  pain  seems  not  infrequently  diminished,  even 
though  no  certain  opinion  can  be  arrived  at  owing  to  the 
psychic  dulness  of  the  patients ;  Mayor  often  found  tender- 
ness in  the  hypogastrium  and  the  breasts. 

Behaviour  of  the  Pupils. — This  is  of  great  significance. 
They  are  frequently  in  the  earlier  stages  of  the  disease  and 
in  conditions  of  excitement  conspicuously  wide,  according  to 
IVJeyer  in  lo  per  cent,  of  the  cases,  as  Weiler  explains, 
t)ecause  of  an  increase,  caused  by  the  morbid  process,  of  that 
cortical  excitement  which  reduces  the  tone  of  the  sphincters. 
Here  and  there  one  observes  a  distinct  difference  in  the  pupils. 
The  light-reaction  of  the  pupils'^  often  appears  sluggish  or 
slight.  Westphal  sometimes  found  distortion  of  the  shape  of 
the  pupils,  obliquely  oval  position,  and  also  passing  failure  of 
the  reaction  to  light  and  accommodation  especially  in  states 
of  profound  stupor,  sometimes  unilateral,  sometimes  bilateral. 
He  suggests  morbid  tension  of  the  musculature  of  the  iris  in 
connection  with  the  general  muscle  tension.  According  to 
Sioli's  observations  similar  disorders  can  be  produced  even 

^  Trepsat,  Etude  des  troubles  physiques  dans  la  demence  precoce.  These.  1905  ; 
Tomaschny  und  Meyer,  Allgem.  Zeitschr.  f.  Psychiatrie,  1909,  845  ;  Pfortner, 
Monatsschr.  f.  Psychiatrie  u.  Neurol,  xxviii.  208 ;  Serieux,  Annales  medico- 
psychol.  1902,  Nov. -Dez. 

2  Westphal,  Deutsche  medizin.  Wochenschr.  1909,  23;  Bumke,  Miinchener 
medizin.  Wochenschr.  1910,  51 ;  Weiler,  Zeitschr.  f.  die  ges.  Neurologic  und 
Psychiatrie  ii.,  lOl. 


78  DEMENTIA  PR/ECOX 

after  the  disappearance  of  the  stupor  by  strong  voluntary 
straining  of  the  muscles.  All  the  disorders  which  have  been 
mentioned  appear  to  be  subject  to  much  change. 

The  pupillary  reaction  to  pain  and  psychic  stimuli  as  well 
as  the  pupillary  movement  which  continuously  accompanies 
the  psychic  life  has  disappeared,  as  Bumke  found,  in  a 
considerable  number  of  cases.  It  must  be  allowed  that  the 
statements  about  the  frequency  of  this  disorder  are  extra- 
ordinarily discrepant  which,  considering  the  difficulty  in 
ascertaining  the  facts,  does  not  appear  surprising.  Bumke 
did  not  once  find  the  psychic  reactions  normal  in  33  cases, 
in  69  per  cent,  he  found  it  lost ;  he  states  that  first  the 
pupillary  movement,  the  permanent  slight  variation  of  the 
width  of  the  pupils,  which  is  only  recognisable  with  the  loupe, 
disappears,  then  the  dilatation  of  the  pupils  caused  by 
psychic  impressions,  lastly  the  pain  reaction.  Hiibner  failed 
to  get  the  psychic  reflexes  in  75  per  cent,  of  51  cases.  Still 
higher  numbers  were  got  by  Sioli  who  found  in  48  cases 
belonging  to  the  domain  of  dementia  priecox  the  psychic 
reaction  and  the  pupillary  movement  absent.  On  the  other 
hand,  Wassermeyer  in  39  cases  observed  absence  of  the  psychic 
reflexes  only  in  1 5  per  cent.  VVeiler  saw  it  in  36  per  cent,  of 
126  cases;  in  another  20  per  cent,  they  were  diminished.  In 
detail  it  was  shown  that  absence  of  pain  reaction  could  be 
ascertained  only  in  36  per  cent.,  a  diminution  in  a  further 
20  per  cent.;  against  that  an  increased  reaction  on  psychic 
and  sensory  stimulation  in  40  per  cent.,  a  diminution  in 
34  per  cent,  of  the  cases.  The  disorders  of  all  these  reactions 
appeared  24  times  among  35  hebephrenics,  41  times  among 

79  catatonics,  6  times  among  12  paranoids;  they  were  there% 
fore  most  frequent  among  the  first.  Weiler  is  inclined  to 
account  for  the  numerical  difference  of  his  results  from  those 
of  other  observers,  disregarding  slight  differences  in  the 
carrying  out  of  the  observations,  essentially  by  the  circum- 
stance that  he  had  mostly  more  recent  cases.  The  dis- 
appearance of  the  reaction  was  observed  in  general  more  in 
advanced  stages  of  the  disease,  but  was  occasionally  to  be 
seen  in  the  early  periods.  One  can  scarcely  be  mistaken,  if 
one  brings  this  failure  of  the  psychic  reaction  into  connection 
with  the  disappearance  of  the  emotional  activities  in  our 
patients,  by  which  they  are  probably  caused.  It  must, 
however,  be  noted  that  Wassermeyer  in  174  healthy  soldiers 
could  establish  in  6  cases  a  considerable  diminution  and  once 
absence  of  the  psychic  pujiillary  reaction,  while  Sioli  found 
it  present  in  25  attendants,  though  to  a  very  varying 
degree. 


BODILY  SYMPTOMS  79 

The  tendon  reflexes  are  often  more  or  less  considerably 
increased,  according  to  Meyer  in  45  per  cent.  ;  according  t(j 
Trepsat  in  59  per  cent;  diminished  in  14,  relatively  12  per 
cent.  Weiler  often  got,  especially  in  stuporous  patients, 
absence  of  the  brake-action,  and  in  consequence  repeated 
after-oscillation.  Meyer  found  in  398  cases  patellar-clonus 
6  times,  ankle-clonus  twice.  Skin  and  mucous  membrane 
reflexes  are  often  weak  ;  Trepsat  found  the  plantar  reflex 
in  64  per  cent,  of  the  cases  diminished,  in  26  per  cent, 
increased. 

Psycho-motor  Domain. — Various  and  profound  disorders 
are  found  here.  Dufour  has  described  disorders  of  equili- 
brium, staggering,  adiadochokinesia,  and  tremor,  which  he 
regards  as  the  expression  of  a  "  cerebellar  "  form  of  dementia 
praecox.  Ermes  ^  has  recorded  curves  of  attitude  in  cataleptic 
patients.  He  found  that  a  fall  of  the  leg  held  horizontally 
only  began  after  205  seconds,  while  in  healthy  persons  it 
made  its  appearance  on  an  average  after  38  seconds,  at  latest 
after  80  seconds.  There  followed  then  either  a  repeated 
jerky  falling  off"  with  tremor  or  a  gradual  sinking.  Before 
complete  relaxation  20  minutes  elapse  with  the  patients;  in 
healthy  persons  rather  more  than  7  minutes.  The  principal 
cause  of  this  power  of  endurance  is  certainly  to  be  sought  for 
in  peculiar  disorders  of  volitional  impulse.  Meanwhile 
Ajello^  has  after  very  comprehensive  investigations  arrived 
at  the  result,  that  the  muscles  of  those  patients,  whom  we 
shall  later  come  to  know  as  catatonics,  show  a  peculiar 
reaction  to  electrical  stimuli.  It  consists  according  to  his 
experiments  in  the  simultaneous  appearance  of  tonic  con- 
.tractions  along  with  genuine  muscle-twitchings.  He  connects 
this  phenomenon  with  a  heightened  irritability  of  the 
sarcoplasm,  as  it  is  only  found  otherwise  in  embryonic, 
fatigued,  anaemic,  or  degenerated  muscles,  and  he  brings  it 
into  relation  with  the  idiopathic  muscular  swellings,  which 
indeed  can  be  demonstrated  not  infrequently  in  our  patients 
at  the  same  time  as  heightened  sensibility  of  the  muscles  to 
percussion. 

Gregor  and  Hansel  found  in  experiments  with  the 
et'gograph  that  the  patients  made  only  a  few  curves  of 
approximately  the  same  height,  and  then  suddenly  gave  out. 
Isserlin  and  Lotmar  have  investigated  the  course. of  simple 
flexion  and  extension  movements  of  the  right  index  finger  in 

^  Ermes,  Uber  die  Natur  der  bei  Katatonie  zu  beobachtenden  Muskelzuslande. 
Diss.  1903. 

^Ajello,  Ricerche  sulle  proprieta  fisiologiche  generali  dei  muscoli  nella 
catatonia,  1907. 


8o  DEMENTIA  PRECOX 

our  patients.  Fig.  13  '  shows  the  course  of  a  finger  movement 
consisting  of  flexion  and  rapid  extension  in  a  healthy  person ; 
Figs.  14  to  17  the  same  iu  catatonic  patients ;  the  rapidity  of 
the  revolving  drum  which  in  Fig.  15  is  reproduced  in  fifths  of 
a  second  was  in  all  approximately  the  same.     Fig.   14  shows 


Fk;.  14. 
Simple  Finger  Movement  in  Catatonia  {a). 


Fig.  13.   Normal  F"inger  Movement. 

apart  from  the  smaller  excursion  of  the  movement,  an 
abnormality  which  frequently  appears  in  catatonics,  though 
not  invariably,  the  interpolation  of  a  perceptible  pause 
between  flexion  and  extension  which  always  follow  each 
other    immediately   in   healthy   persons,   at   the   same   time 


Flc.  15.  Simple  Finger  Movement  in  Catatonia  (d). 


extension  is  slower  than  normal.  We  are  here  reminded  of 
the  stiffness  and  rigidity  which  strike  us  so  frequently  in 
catatonic  movements.  The  abnormalities  seen  in  Fig.  15 
are  much  greater,  though  certainly  they  do  not  appear  so 
frequently.  Here  there  is  first  a  preliminary  extension  before 
flexion,  that  is  an  opposing  impulse  which  is  seen  in 
healthy  persons,  as  in  Fig.  13,  at  most  as  a  slight "  depression." 

'  The  whole  series  is  reduced  two-thirds. 


BODILY  SYMPTOMS 


81 


Fig.  1 6. 
Simple  Finger  Movement  in  Catatonia  (< ). 


The  recoil  of  the  finger  immediately  succeeds  flexion,  but  it 
is  suddenly  checked  in  the  middle  of  its  descent  and  then 
the  finger  returns  with  oscillations  to  the  original  position. 
The  straightforward  course  with  which  the  required  move- 
ment is  performed  in 
healthy  persons  is  ac- 
cordingly influenced  in 
patients  occasionally  by 
all  sorts  of  counter  im- 
pulses and  checks.  The 
other  curves  got  from 
the  same  patient,  as  they 
are  reproduced  in  Figs. 
1 6  and  17,  .show  still 
other  results.  In  Fig.  16 
a  repeated  oscillation  of  opposing  impulses  meets  us ;  at  the 
end  the  finger  persists  in  the  flexed  position.  Fig.  17  shows 
a  similar  proceeding  after  a  movement  of  flexion  carried  out 
correctly  at  the  beginning.  Among  these  curves  there  were 
frequently  some  that  followed  a  normal  course. 

Rhythmical  movements 
also,  which  in  healthy  per- 
sons run  their  course  in 
the  form  of  flexion  and 
recoil  just  like  a  machine, 
show  at  the  transition  to 
extension  the  same  hesita- 
tion as  the  simple"reaction 
movements."  Fig.  18 
represents  such  a  series  of 
continuous  pendulum 
movements,  which  keep 
time,  of  a  finger  of  a  healthy  person  ;  Fig.  19  shows  the 
same  in  the  case  of  a  catatonic;  the  time  record  which  is 
reproduced  gives  the  hundredth  parts  of  a  second. 

The  seizures  which  have  already  been  very  well  described 
by  Kahlbaum  and  Jensen  deserve  special  notice.  They  are 
mostly  attacks  of  vertigo,  fainting  fits,  or  epileptiform  con- 
vulsions, which  occur  in  our  patients,  sometimes  as  an 
isolated  occurrence,  sometimes  more  frequently.  More 
rarely  there  are  spasms  in  single  muscle  groups  (face,  arm), 
tetany  or  even  apoplectiform  seizures  with  paralysis  which 
lasts  for  a  considerable  time,  but  I  was  told  of  some  such 
cases  in  the  previous  histories.  Once  I  saw  profound 
collapse  with  spasms  on  the  left  side  and  in  the  right  facial 
nerve.     A  seizure  is  not  very  infrequently  the  first  sign    of 

F 


Fig.  17. 
Simple  Finger  Movement  in  Catatonia  (d). 


82  DEMENTIA   PR/ECOX 

the  approaching  disease.  1  observed  among  others  the  case 
of  an  older  student  who  had  been  specially  gifted  from  youth. 
He  was  suddenly  attacked  by  profound  coma  from  which  he 
only  gradually  awoke.  Except  for  a  slight  difference  in  the 
pupils,  facial  phenomenon,  and  great  increase  of  the  refle.xes, 
there    was    no    trace    of  cerebral    symptoms,   but    when    I 


Fig.  i8.  Normal  Rhythmical  Finger  Movements. 

examined  the  patient  a  few  weeks  later,  he  exhibited  the 
well-marked  picture  of  premature  weak-mindedness,  which 
continued  for  years.  Hiifler  describes  also  equivalents  of 
catatonic  seizures,  in  which  lie  includes  transitory  disorders 
of  the  innervation  of  the  arm,  of  the  musculature  of  the  face, 
of  the   tongue,   panesthesiae,   pains,   vascular   and    pupillary 


Fn;.  19.  Rhythmetical  Finger  Movements  in  Catatonia. 

disorders,  vomiting,  attacks  of  sweating  with  or  without 
clouding  of  consciousness.  All  these  seizures  are  more 
common  in  the  female  sex  than  in  the  male.  I  found  them 
in  my  series  in  about  16  per  cent.,  and  in  the  Heidelberger 
patients,  who  were  observed  for  a  longer  time,  in  19  per 
cent,   of   all   cases.      But   besides  that  in  a  whole  series   of 


BODILY  SYMPTOMS  83 

patients  (6  per  cent,  of  the  men,  3  per  cent,  of  the  women) 
spasms  or  fainting  fits  had  occurred  previously  in  youth, 
about  which  it  must  for  the  present  remain  doubtful  whether 
any  connection  with  the  psychic  disorder  may  be  ascribed  to 
them.  Some  patients  had  suffered  from  chorea.  Urstein 
records  seizures  in  8  per  cent,  of  the  men  and  in  19  per  cent, 
of  the  women.  In  one  case  I  saw  the  development  of  a 
profound  catatonia  after  the  existence  for  many  years  of 
undoubted  epileptic  seizures  to  which  then  hysteroid  seizures 
were  added.  And  otherwise  hysteroid  spasms  and  paralyses 
are  often  observed  besides  aphonia,  singultus,  sudden  erection, 
local  contractures,  and  similar  phenomena. 

The  spasmodic  phenomena  in  the  musculature  of  the 
face  and  of  speech,  which  often  appear,  are  extremely  peculiar 
disorders.  Some  of  them  resemble  movements  of  expression, 
wrinkling  of  the  forehead,  distortion  of  the  corners  of  the 
mouth,  irregular  movements  of  the  tongue  and  lips,  twisting 
of  the  eyes,  opening  them  wide,  and  shutting  them  tight,  in 
short,  those  movements  which  we  bring  together  under  the 
name  of  making  faces  or  grimacing;  they  remind  one  of  the 
corresponding  disorders  of  choreic  patients.  Nystagmus  may 
also  belong  to  this  group.  Connected  with  these  are  further, 
smacking  and  clicking  with  the  tongue,  sudden  sighing, 
sniffing,  laughing,  and  clearing  the  throat.  But  besides,  we 
observe  specially  in  the  lip  muscles,  fine  lightning-like  or 
rhythmical  twitchings,  which  in  no  way  bear  the  stamp  of 
voluntary  movements.  The  same  is  the  case  in  the  tremor 
of  the  muscles  of  the  mouth,  which  appears  sometimes  in 
speaking  and  which  may  completely  resemble  that  of 
paralytics.  In  a  great  number  of  patients  1  observed  distinct 
twitchings  of  the  musculature  of  the  mouth  on  tapping  the 
lower  branches  of  the  facial  nerves.  Occasionally  one  sees 
uneven  muscle- tension  on  the  two  sides  of  the  face 
temporarily  or  for  a  longer  time,  on  which  Hufler  has  laid 
stress.  The  out-spread  fingers  often  show  fine  tremor.. 
Several  patients  continually  carried  out  peculiar  sprawling, 
irregular,  choreiform,  outspreading  movements,  which  I  think 
I  can  best  characterise  by  the  expression  "  athetoid  ataxia." 

Aphasia. — In  two  cases  it  was  possible  during  a  sf:ate 
of  dull  stupor  to  demonstrate  distinct  aphasic  disorders. 
The  patients  were  unable  to  recognise  and  to  name  the 
objects  laid  in  front  of  them  although  they  could  speak 
and  were  evidently  exerting  themselves  to  give  the  required 
information.  Repeatedly  after  long  consideration  the  wrong 
names  came  out.  The  disorder  disappeared  again  after  a 
few  hours. 


84  DEMENTIA  PRECOX 

Vasomotor  disorders  are  very  wide  spread  in  our 
patients.  Above  all  one  notices  cyanosis  of  the  hands,  less 
of  the  feet,  the  nose  and  the  ears ;  from  the  deep  blue 
colour  of  the  skin,  dilated  arterial  areas  are  sometimes  dis- 
tinguished as  bright  red,  sharply  circumscribed  spots,  which 
can  be  artificially  produced  by  pressure.  Further  there  are 
found  circumscribed  areas  of  oedema,  congestion  of  the 
head,  vivid  blushing,  dermatography  in  all  degrees,  especially 
in  the  beginning  of  states  of  stupor.  Trepsat  was  able  in 
one  case  after  48  hours  to  make  the  dermatographic  writing 
again  visible  by  light  rubbing  with  the  finger-tip  ;  he  reports 
also  eruptions  and  even  ulcers  of  "  trophic "  origin.  The 
activity  of  the  heart  is  subjected  to  great  fluctuations  ; 
sometimes  it  is  retarded,  more  frequently  it  is  somewhat 
accelerated,  often  also  it  is  weak  and  irregular  ;  many  patients 
complain  of  palpitation. 

Blood-pressure  is  as  a  rule  lowered  ;  it  fluctuates,  how- 
ever, considerably.  Weber  found  for  systolic  and  diastolic 
pressure,  pulse  pressure  and  pulse  frequency  low  or  at  most 
average  values  especially  in  stuporous  patients.  Lugiato 
and  Ohannessian,  as  well  as  Lukacs,  were  able  to  ascertain 
frequently  a  disproportion  between  blood-pressure  and  pulse 
frequency.  Bumke  and  Kehrer  observed  in  plethysmo- 
graphic  experiments  in  catatonic  stupor  absence  of  decrease 
in  volume,  as  well  as  of  changes  in  pulse  and  respiration,  on 
the  application  of  the  stimuli  of  cold  and  pain,  and  they 
point  out  the  relationship  of  this  disorder  to  the  absence 
of  the  psychic  pupillary  reaction. 

Respiration  is  according  to  d'Ormea's  statements  some- 
what accelerated  and  very  deep,  and  it  shows  many  irregu- 
larities especially  in  expiration.  Sometimes  severe  outbursts 
of  perspiration  are  observed. 

The  secretion  of  saliva  is  frequently  increased,  usually 
only  temporarily,  much  seldomer  permanently  ;  I  was  able 
from  one  patient  to  collect  in  6  hours  375  ccm.  of  saliva. 
The  analysis  carried  out  by  Rohde  in  one  case  gave  a 
specific  gravity  of  1*0026  and  a  nitrogen  content  of  oigi 
per  cent.,  values  which  are  at  the  lower  limit  of  the  normal, 
and  do  not  point  to  the  origin  of  the  flow  of  saliva  b)' 
stimulation  of  the  sympathetic.  In  some  patients  rumina- 
tion is  observed,  especially  in  the  terminal  states. 

Temperature  is  usually  low,  sometimes  sub-normal  with 
occasional  reversal  and  small  range  of  the  daily  fluctuations. 
Fig  20  shows  the  course  of  the  temperature  in  the  last 
weeks  of  life  of  a  patient  who  was  considerably  excited  and 
who   did    not   exhibit   any   apparent   bodily   ailment.     The 


BODILY  SYMPTOMS 


85 


readings,  which  had  already  for  more  than  3  weeks  previously 
almost  always  been  under  37"  C.  and  on  one  occasion  had 
sunk  to  34"2''  C,  are  repeatedly  lower  in  the  evening  than 
in  the  morning ;  they  sink  in  the  two  last  weeks  of  life  first 
to  33"4''  C.  and  then  with  a  single  jump  rise  again  to  38'5''  C. 
and  even  to  39  i"  C.  towards  the  end  of  life. 

The  menses  are  usually  absent  or  irregular,  according 
to  Pfortner's  statements  in  two-thirds  of  the  recent  cases. 

Blood  Changes. — The  obscurity  that  hangs  over  the 
causes  of  dementia  praecox  has  been  a  frequent  motive  for 
the  examination  of  the  blood-picture  and  of  metabolism, 
but  the  findings  up  to  now  are  not  very  satisfactory.     Lund- 


10  11  12  13  14  15  16  17  18  19  20  21  II   23  24  25 


Fig  20. — Course  of  the  body  temperature  at  the  close  of  life  of  a  catatonic 

patient. 

wall  found  in  general  no  change  in  the  blood,  but  '•  blood 
crises"  with  decrease  in  the  red  and  increase  in  the  white 
corpuscles  which  appeared  periodically.  Bruce  and  Peebles 
describe  in  the  acute  periods  of  the  disease  a  moderate 
increase  specially  of  the  polynuclears  and  the  large  mono- 
nuclears, which  in  stupor,  but  still  more  in  the  terminal 
stages,  gives  place  to  a  decrease,  specially  in  the  pclynuclear 
leucocytes.  Bruce  has  even  made  the  attempt  to  establish 
blood-pictures  peculiar  to  each  form  of  insanity  and  from 
them  to  draw  prognostic  conclusions,  an  undertaking,  which 


86  DEMENTIA  PR/ECOX 

in  face  of  the  many  diverse  statements  must  be  regarded 
as  premature.  Heilemann  also  reports  a  small  increase  of 
the  white  blood  cells  with  comparative  decrease  of  the 
polynuclear  forms.  Sandri  emphasised  similar  findings 
especially  in  catatonic  states.  Dide  and  Chenais'  observed 
an  increase  of  the  eosinophil  cells,  Pighini  and  Paoli  an 
increase  in  the  size  of  the  red  blood  corpuscles  with  a  ring- 
shaped  arrangement  of  the  haemoglobin.  Itten  was  not 
able  to  establish  any  characteristic  findings  in  the  blood. 
However,  in  some  chronic,  resistive,  demented  patients  fairly 
high  leucocyte  counts  were  found,  and  in  some  dull  depressed 
patients  comparatively  low  counts. 

Berger  has  made  the  attempt  to  prove  the  presence  of 
to.xic  material  in  the  blood  of  catatonics  by  injecting  serum 
of  the  patients  into  the  occipital  lobe  of  dogs ;  he  found 
that  muscle  twitchings,  apathy  and  a  tendency  to  forced 
attitudes  appeared. 

Investigations  in  metabolism  -  have  also  frequently  been 
carried  out.  In  acute  cases  Pighini  observed  increased 
excretion  of  nitrogen,  phosphorus,  and  sulphur,  of  urea,  uric 
acid,  and  xanthin  bases,  which  he  connects  with  increased 
breaking  down  of  nucleoproteins  containing  phosphorus 
and  sulphur.  Allers  has  called  attention  to  the  fact  that 
here  possibly  insuflficient  nourishment  might  play  an  essential 
part  in  the  states  of  excitement..  During  the  chronic  course, 
on  the  contrary,  there  is  said  to  be  retention  of  phosphorus 
and  nitrogen,  and  a  loss  of  lime  and  sulphur.  Rosenfeld 
invariably  observed  retention  of  nitrogen,  1-2  grm.  daily.  A 
considerable  lowering  of  the  need  for  oxygen  which  cannot 
be  removed  by  thyroidin  was  shown  by  the  researches  of 
Bornstein.  The  restriction  of  the  oxidation  processes  which 
is  in  healthy  persons  already  noticeable  between  the  15th 
and  25th  years  undergoes  here  according  to  his  investiga- 
tions a  morbid  increase.  Grafe^  also  found  in  catatonic 
stupor  a  distinct  slowing  of  metabolism,  a  lowering  of  heat 
production  to  39  per  cent,  of  the  normal,  the  increase  of 
oxidation  after  the  intake  of  nourishment  showed  a  slower 
development.  In  the  urine  of  the  patients,  sugar  is  occasion- 
ally found  ;  it  probably  is  always  a  case  of  alimentary 
glycosuria,  which  could  be  fairly  frequently  demonstrated. 
Lugiato  found  retarded  excretion  of  injected  la:vulose.  The 
elimination  of  methylene  blue  and  iodide  of  potassium  began 

'  Dide  et  Chenais,  Annates  nK^dico-psychologiques  1902,  2,  406. 
-  Pighini,  Kivista  sperimentale  di  frenia'.ria  xxxiii,  566  ;  d'Ormea  e  Maggiotto, 
Rifuima  medica,  26,  1905. 

'•'  Grafe,  Deutsches  Arohiv  f.  klin.  Medizin,  102,  15. 


BODILY  SYMPTOMS 


87 


according  to  the  researches  of  d'Ormea  and  Maggiotto  con- 
siderably later  than  in  healthy  persons  and  lasted  longer. 
In  the  cerebro-spinal  fluid  Tighini  found  in  43  per  cent,  of 
his  patients  cholesterin  which  he  never  could  demonstrate 
in  healthy  persons. 

In  a  series  of  cases  I  observed  diffuse  enlargements  of  the 
thyroid  gland,  occasionally  the  disappearance  of  such  enlarge- 
ments immediately  before  the  first  appearance  of  morbid 
phenomena,  also  repeated  rapid  change  in  the  size  of  the 
gland  during  the  development  of  the  malady.  Occasionally 
exophthalmos  and  tremor  were  present.  Lastly  we  noticed, 
as  the  relatives  of  the  patients  also  did,  not  infrequently  a 
turgid  appearance  and  a  thickening  of  the  skin  reminiscent 
of  myxoedema,  especially  in  the  face.     Unfortunately  these 


tao 


X- 

J^^-r 

^^^^       ^ 

^-^T^K 

\ 

_     .,       .        +. , 

Fig.  21. — Body-weightin  catatonic 
stupor  with  dementia. 


Fig.  22. — Body-weight  in  catatonic 
excitement. 


findings  cannot  be  made  use  of  further  in  the  meantime 
because  of  the  frequency  of  thyroid  disease  amongst  us. 
Very  frequently  anaemic  and  chlorotic  conditions  appear  to 
be  present. 

Sleep  and  Food. — During  the  whole  development  of  the 
disease  the  sleep  of  the  patients  is  frequently  disturbed  even 
when  they  are  lying  quiet.  The  taking  of  food  fluctuates 
from  complete  refusal  to  the  greatest  voracity.  The  body- 
weight  usually  falls  at  first  often  to  a  considerable  degree, 
even  to  extreme  emaciation,  in  spite  of  the  most  abundant 
nourishment.  Later,  on  the  contrary,  we  see  the  weight  not 
infrequently  rise  quickly  in  the  most  extraordinary  way,  so 
that  the  patients  in  a  short  time  acquire  an  uncommonly 
well-nourished  turgid  appearance.  Sometimes,  in  quite  short 
periods,  very  considerable  differences  in  the  body-weight  are 


88 


DEMENTIA  PR/ECOX 


noticed,  probably  in  connection  with  fluctuations  of  the 
amount  of  water  contained  in  the  tissues.  Of  the  curves 
which  are  here  reproduced,  Fig.  21,  shows  the  body-weight  in 
the  usual  course  of  a  case  of  catatonic  stupor  termitiating 
in  dementia  of  middle  grade.  Although  after  the  awakening 
from  stupor  slight  excitement  set  in,  the  weight  increased 
very  much.  Fig,  22  was  obtained  from  the  patient  whose 
temperature  curve  is  given  above,  and  who  in  spite  of  the 
most  careful  nursing  and  abundant  nourishment  sank  in 
marasmus  of  the  highest  degree  without  any  organic  disease. 
Very  great  fluctuations  of  the  body-weight,  from  the  initial 
weight  to  the  double  of  it,  is  shown  in  Fig.  23,  which  was 


fff 

til 

r 

v\ 

/ 

^ 

/ 

\y' 

w 

fg 

1 

1 

n 

.  / 

TV 

1 

ID 

/ 

A^ 

^ 

J 

DO 

/ 

\r 

Jfi_ 

' 

I^J^-P. 

i^ 

r/^r^I 

J 

=7      ^ 

V 

Fig.  23. — Bo()y-\vei{;ht  in  alternalion  of  stupor  1-ig.  24. — fluctuations  in  bo<iy- 

and  excitement  with  dementia.  weight  in  the  beginning  of  a 

case  of  dementia  priecox. 

obtained  from  a  young  catatonic.  The  patient  after  an  initial 
alternation  of  stupor  and  excitement  came  to  us,  recovered  at 
first,  but  then  sank  with  diminution  of  the  body  weight  again 
into  deep  stupor,  from  which  he  awoke  after  some  months  to 
increase  rapidly  in  weight  to  an  extraordinary  extent ;  but  at 
the  same  time  the  transition  to  depressive  dementia  with 
some  features  of  silly  affectation  had  taken  place.  Lastly, 
Fig.  24  shows  in  a  commencing  dementia  pra^cox  a  series  of 
fairly  regular  fluctuations  which  kept  pace  with  an  alternation 
of  stupor  and  greater  clearness.  Later  this  regularity  ceased, 
and  it  came  to  permament  dementia. 


CHAPTER   V. 
CLINICAL    FORMS. 

The  presentation  of  clinical  details  in  the  large  domain 
of  dementia  praecox  meets  with  considerable  difficulties, 
because  a  delimitation  of  the  different  clinical  pictures  can 
only  be  accomplished  artificially.  There  is  certainly  a  whole 
series  of  phases  which  frequently  return,  but  between  them 
there  are  such  numerous  transitions  that  in  spite  of  all  efforts 
it  appears  impossible  at  present  to  delimit  them  sharply  and 
to  assign  each  case  without  objection  to  a  definite  form.  We 
shall  be  obliged  therefore,  as  in  paralysis,  to  content  ourselves 
at  first  for  the  sake  of  a  more  lucid  presentation  with  describ- 
ing the  course  of  certain  more  frequent  forms '  of  the  malady 
without  attributing  special  clinical  value  to  this  grouping. 

As  such  forms  I  have  hitherto  separated  from  each  other 
a  hebephrenic,  a  catatonic,  and  a  paranoid  group  of  cases. 
This  classification  has  been  frequently  accepted  with  many 
modifications,  specially  concerned  with  the  clinical  position 
of  the  paranoid  diseases,  as  also  by  Bleuler  in  his  monograph 
on  schizophrenia ;  he  adds,  however,  to  it  the  insidious 
"dementia  simplex"  as  a  special  form.  Racke  has  made 
other  attempts  at  classification  ;  he  separates  out  "depressive," 
"  confused  excited,"  "  stuporous,"  "  subacute  paranoid  "  forms 
and  a  "  catatonia  in  attacks."  Wieg-Wickenthal  differentiates 
"dementia  simplex,"  "hebephrenia"  with  pseudomanic 
behaviour,  "  depressive  paranoid  forms "  and  catatonia. 

The  undoubted  inadequacy  of  my  former  classification 
has  led  me  once  more  to  undertake  the  attempt  to  make  a 
more  natural  grouping,  as  I  have  in  hand  a  larger  number  of 
possibly  more  reliable  cases.  For  this  purpose  there  were  at 
my  disposal  about  500  cases  in  Heidelberg  which  had  been 
investigated  by  myself,  in  which  according  to  their  clinical 
features,  as  well  as  according  to  the  length  of  the  time  that 
had  passed,  the  ultimate  issue  of  the  morbid  process  could  be 
accepted  with  considerable  probability.  "  Recovered  "  cases 
were  not  taken  into  account  because  of  the  uncertainty  of 
their  significance  which  still  exists,  but  only  such  cases  as 

'  Sante  de  Sanctis,  Rivista  sperimentale  de  freniatria,  xxxii,  141. 


90  DEMENTIA  VRMCOX 

had  led  to  profound  dementia  or  to  distinctly  marked  and 
permanent  phenomena  of  decreased  function.  On  grounds 
which  will  be  discussed  later,  it  is,  as  I  believe,  not  to  be 
assumed  that  by  this  choice  definite  clinical  types  have 
quite  fallen  out  of  the  scope  of  our  consideration  ;  at  most  a 
certain  displacement  in  the  frequency  of  the  individual  forms 
would  be  conceivable. 

The  result  of  this  attempt  at  a  classification  agrees  in 
many  points  with  the  statements  of  the  above-mentioned 
investigators.  First  I  also  think  that  I  should  delimit  simple 
insidious  dementia  as  a  special  clinical  form.  Next  in  the 
series  comes  hebephrenia  in  the  narrower  sense  of  silly 
dementia  which  was  first  described  by  Hecker.  A  third 
group  is  composed  of  the  simple  depressive  or  stuporous 
forms,  a  fourth  of  states  of  depression  with  delusions.  In  a 
fifth  form  I  have  brought  together  the  majority  of  the  clinical 
cases  which  go  along  with  conditions  of  greater  excite- 
ment ;  one  could  speak  of  an  agitated  dementia  praecox.  To 
it  is  nearly  related  the  sixth  form,  which  includes  essentially 
the  catatonia  of  Kahlbaum,  in  which  peculiar  states  of 
excitement  are  connected  with  stupor.  A  more  divergent 
picture  is  seen  in  the  seventh  and  eighth  groups,  in  which  the 
'  cases  are  placed  which  run  a  paranoid  course,  according  to 
whether  they  end  in  the  usual  terminal  states  of  dementia 
praecox  or  in  paranoid,  relatively  hallucinatory,  weakminded- 
ness.  We  shall  then  subject  to  special  consideration  the 
small  number  of  observations,  which  present  the  remarkable 
phenomenon  of  confusion  of  speech  along  with  perfect  sense 
and  fairly  reasonable  activity. 

Dementia  Simplex. 

Simple  insidious  dementia  as  it  was  described  by  Diem  ^ 
under  the  name  dementia  simplex,  consists  in  an  impoverish- 
ment  and  devastation  of  the  luhole  psychic  life  which  is 
accomplisJud  quite  imperceptibly.  The  disease  begins  usually 
in  the  years  of  sexual  development,  but  often  the  first 
slight  beginnings  can  be  traced  back  into  childhood.  On 
the  other  hand  Pick  has  also  described  a  "  primary  progressive 
dementia  of  adults,"  but  it  is  certainly  very  doubtful  whether 
it  may  be  grouped  with  dementia  prc-ecox.  In  our  patients 
a  deterioration  of  mental  activity  becomes  very  gradually 
noticeable.  The  former  good,  perhaps  distinguished,  scholar 
fails  always  more  conspicuously  in  tasks  which  till  then 
he    could    carry    out    quite    easily,    and    he    is    more    and 

'  Diem,  Archiv  f.  Psychiatric  xxxvii.  in. 


CLINICAL  FORMS  91 

more  outstripped  by  his  companions.  He  appears  absent- 
minded,  thoughtless,  makes  incomprehensible  mistakes,  cannot 
any  longer  follow  the  teaching  rightly,  does  not  reach  the 
standard  of  the  class.  While  pure  exercises  of  memory  are 
perhaps  still  satisfactory,  a  certain  poverty  of  thought, 
weakness  of  judgment  and  incoherence  in  the  train  of  ideas 
appears  always  more  distinctly.  Many  patients  try  by 
redoubled  efforts  to  compensate  for  the  results  of  their 
mental  falling  off,  which  is  at  first  attributed  by  parents 
and  teachers  to  laziness  and  want  of  good  will.  They  sit 
the  whole  day  over  their  work,  learn  by  heart  with  all  their 
might,  sit  up  late  at  night,  without  being  able  to  make  their 
work  any  better.  Others  become  idle  and  indifferent,  stare 
for  hours  at  their  books  without  reading,  give  themselves  no 
trouble  with  their  tasks,  and  are  not  incited  either  by  kindness 
or  severity. 

Hand  in  hand  with  this  decline  of  mental  activity  there 
is  a  change  of  temperament,  which  often  forms  the  first 
conspicuous  sign  of  the  developing  malady.  The  patients 
become  depressed,  timid,  lachrymose,  or  impertinent,  irritable, 
malicious  ;  sometimes  a  certain  obstinate  stubbornness  is 
developed.  The  circle  of  their  interests  becomes  narrower  ; 
their  relations  to  their  companions  become  cold  ;  they  show 
neither  attachment  nor  sympathy.  Not  infrequently  a 
growing  estrangement  towards  parents  and  brothers  and 
sisters  becomes  noticeable.  The  patients  remain  indifferent 
to  whatever  happens  in  the  family  circle,  shut  themselves  up, 
limit  the  contact  with  their  relatives  to  the  least  possible. 
Bleuler  brings  forward  here  as  a  frequent  explanation  the 
"  (Edipus  complex,"  the  concealed  sexual  inclination  to  one 
of  the  parents  and  the  jealous  emotions  which  arise  from  it. 
I  consider  that  the  generalization  of  that  kind  of  case,  which 
is  certainly  very  rare,  as  belonging  to  the  system  of  Freud, 
is  wholly  without  foundation.  It  seems  much  more  natural 
to  me  to  explain  the  antagonism  to  relatives  by  the  gloomy 
feeling  of  inferiority  and  the  defiant  resistance  to  it,  but 
above  all  by  the  common  experience  that  for  a  long  time  it 
has  been  the  habit  of  the  relatives  to  trace  the  morbid 
phenomena  back  to  a  moral  offence,  and  to  meet  them  with 
painful  reprimands  and  measures.  Similar  antagonism  is 
also  seen  quite  commonly  to  develop  in  the  relations  with 
degenerate,  wayward  children. 

Ambition  and  pleasure  in  the  usual  games  and  occasional 
occupations  become  extinct;  wishes  and  plans  for  the  future 
are  silent ;  inclination  and  ability  for  useful  occupation 
disappear.     The  patient  has  neither  endurance    nor   under- 


92  DEMENTIA  PR/ECOX 

standing,  works  confusedly,  begins  everything  the  wrong  way 
about,  triesas  far  as  possible  to  withdraw  himself  from  claims 
on  him.  He  remains  lying  in  bed  for  days,  sits  about 
anywhere,  trifles  away  his  time  in  occupations  of  no  value, 
devours  perhaps  without  choice  and  without  understanding 
chance  and  unsuitable  literature,  lives  one  day  at  a  time 
without  a  plan.  A  few  patients  have  indeed  at  times  a 
certain  feeling  of  the  change,  which  takes  place  in  them,  often 
in  hypochondriacal  colouring  ;  but  the  majority  sink  into 
dulness  without  being  in  any  way  sensible  of  it.  Sometimes 
a  certain  restlessness  is  shown  which  causes  the  patient  to 
take  extended  walks,  to  run  away  without  an)-  plan,  to 
undertake  aimless  journeys.  Alcohol  is  for  him  a  special 
danger,  he  gives  way  to  its  temptations  without  resistance, 
and  then  very  rapidly  comes  down  in  the  world,  and  comes 
into  conflict  with  public  order  and  criminal  law.  That 
happens  the  more  easily  as  many  patients  are  very  sensitive 
to  intoxicating  drinks. 

In  these  circumstances  the  inability  of  the  patients  to 
undergo  the  preparatory  training  or  to  attain  to  the  calling 
which  was  planned  for  him  becomes  always  more  clear.  He 
passes  no  more  examinations,  is  sent  away  as  useless  from 
every  apprenticeship,  does  not  fit  in  anywhere,  nor  does  he 
feel  at  home  in  anything.  After  all  possible  unsuccessful 
attempts  to  get  them  settled,  many  patients  in  the  end 
remain  idle  at  home,  where  they  either  lead  a  quiet  existence 
without  activity  and  without  desire,  without  any  disorder  of 
note,  or  they  live  their  own  lives,  and  as  capricious  oddities 
try  the  patience  of  their  relatives  severely.  Other  patients 
succeed  in  getting  a  foothold  in  some  subordinate  calling, 
especially  in  gardening  and  agriculture,  where  in  narrow 
surroundings  they  are  in  a  position  to  fulfil  a  limited  number 
of  duties.  Others  again,  as  no  other  expedient  is  known,  arc 
provided  with  some  money  and  sent  to  America,  where  they 
immediately  go  to  the  bad ;  some  manage  to  enter  the 
Foreign  Legion  and  are  there  again  turned  away  after  severe 
discipline  and  punishment.  A  considerable  number  in  the 
end  fall  into  the  crowd  of  beggars  and  vagabonds,  and 
oscillate  hither  and  thither  in  a  half-witted  state  from  year's 
end  to  year's  end  between  public  highway  and  workhouse, 
where  ever  anew  the  hopeless  attempt  is  made  "  to  turn  them 
into  useful  people  again." 

The  development  of  this  clinical  picture  invariably  takes 
a  series  of  years.  It  may  stand  still  for  a  shorter  or  longer 
time,  but  on  the  other  hand  it  may  occasionally  experience  a 
more  sudden  exacerbation.     The  terminal  result  to  which  the 


CLINICAL  FORMS  93 

malady  leads  is  of  varied  character,  as  it  may  make  a  final 
halt  on  each  step  of  its  development.  Thus  then  we  see  in 
a  series  of  cases  a  very  slight  loss  in  the  psychic  life  remain, 
which  only  becomes  noticeable  by  comparison  with  former 
behaviour,  while  in  others  a  marked  psychic  decline  comes 
into  existence. 

The  frequency  of  the  malady  is  probably  fairly  large,  even 
if  only  a  small  number  of  the  cases  are  considered  as  morbid 
at  all  or  even  fall  into  the  hands  of  the  alienist.  Who  cannot 
call  to  mind  companions  of  his  youth  who  at  first  gave  just 
ground  for  certain,  perhaps  brilliant,  hopes,  but  then  from 
some  point  of  their  development  onwards  failed  in  an  incom- 
prehensible way  ?  It  is  here  a  question  of  these  young  people 
who,  without  palpable  cause  and  without  any  special  morbid 
phenomena,  simply  trifle  away  the  time,  or  are  only  able  to 
gain  a  position  in  life  far  under  their  original  prospects. 
Neither  they  nor  their  relatives  have  perhaps  any  idea 
that  a  morbid  process  has  taken  place;  only  the  knowledge 
of  cases  which  run  a  severer  course,  suggests  the  thought 
that  such  slight  losses  in  psychic  ability  might  also  be 
due  to  dementia  prsecox.  Here  and  there,  perhaps,  also 
individual  caprices,  peculiarities  or  temperamental  inadequacy 
in  people  who  are  otherwise  well  developed  psychically 
are  to  be  regarded  as  residua  of  slight  morbid  disorders 
of  the  same  kind  as  the  disease  here  discussed,  if  it  can 
be  proved  that  they  were  first  developed  in  a  definite  period 
of  life. 

When  the  disease  comes  to  a  standstill,  it  may  mean  a 
final,  though  incomplete,  recovery  ;  but  sooner  or  later  the 
morbid  process  may  again  progress.  We  are  not  able  at 
present  to  say  whether  the  latter  is  always  possible,  or  if  in 
many  cases  it  is  excluded.  A  really  profound  dementia, 
without  fairly  acute  exacerbations,  with  a  continuous  develop- 
ment of  the  malady,  only  slowly  progressive,  does  not  seem 
to  occur.  On  the  contrary,  a  dementia  simplex  which  lasts 
for  many  years,  even  for  decades,  forms  often  enough  the 
introduction  to  one  of  the  forms  of  dementia  prsecox  which 
goes  on  to  profound  dementia,  and  which  will  be  discussed 
later  on.  If  one  will,  one  may  also  regard  dementia  simplex 
in  a  certain  way  as  the  first  period  of  dementia  praecox.  The 
cases  which  belong  to  it  halt  on  one  of  the  steps  which  form 
this  period,  while  in  the  remaining  forms  there  occurs  pro- 
gress of  the  malady  beyond  that  point.  But  a  first  period 
in  the  sense  of  the  term  dementia  simplex  can  certainly  not 
always  be  proved,  except  in  a  certain  number  of  observed 
cases. 


94  DEMENTIA  PRyECOX 

SiLLv  Dementia. 

That  form  of  dementia  pra;cox  which  we  have  called 
above  "  silly  dementia,"  is  in  many  respects  nearly  related 
to  simple  insidious  dementia.  In  its  clinical  picture  there 
appears  besides  the  progressive  devastation  of  the  psychic 
life  incoherence  in  thinking,  feeling,  and  action.  It  corre- 
sponds, as  already  mentioned,  in  its  principal  features  to 
the  clinical  picture  of  hebephrenia  which  was  described  by 
Hecker '  in  1871  as  a  type  in  connection  with  the  researches 
of  Kahlbaum.  Hecker  at  that  time  brought  together  under 
this  term  a  group  of  cases  in  which,  after  an  introductory 
stage  of  melancholy,  a  stage  of  mania  develops  and  then 
rapidly  makes  room  for  a  quite  peculiar  weak-minded  con- 
dition. Daraszkiewicz  '  then  enlarged  the  idea  of  hebephrenia 
by  including  also  the  "depressed  forms"  which  lead  to  pro- 
found insanity. 

The  development  of  the  disease  is  accomplished  in  almost 
four-fifths  of  the  cases  quite  gradually;  often  an  insidious 
change  of  the  psychic  personality  precedes  the  appearance  of 
more  distinct  morbid  phenomena  by  many  years.  In  the 
remaining  patients  the  disorder  begins  in  subacute  form  ;  in 
a  few  cases  it  breaks  out  suddenly.  In  the  preliminary  stage 
there  are  sometimes  nervous  troubles,  complaints  of  lassitude, 
headaches,  feeling  of  giddiness,  fainting-fits,  irritability,  dis- 
orders of  sleep.  The  patients  become  absent-minded,  forget- 
ful, negligent ;  they  tire  easily,  they  cannot  collect  their 
thoughts  any  more ;  they  appear  lacking  in  ideas  and  under- 
standing, they  are  silly  and  lazy  ;  they  fail  in  daily  tasks, 
change  their  occupation,  because  it  is  too  difficult  for  them, 
set  aside  their  work,  or  give  it  up  entirely. 

Here  and  there  hallucinations  appear.  The  patients  see 
apparitions,  witches,  dead  people,  will-o'-the-wisps,  the  devil 
with  a  white  beard,  little  black  mannikins,  which  sit  down  on 
their  breasts.  A  patient  saw  "  the  three  most  beautiful  crowns 
in  the  world";  "black  points  were  flung  at"  another.  They 
hear  good  or  evil  spirits,  the  Edison  phonograph  speaking, 
voices  "  talking  always  of  love";  things  are  spoken  into  their 
head  ;  their  thoughts  become  loud,  their  suspenders  turn  into 
snakes;  their  food  appears  green  from  arsenic;  it  smells  of 
the  water-closet. 

Delusions. — Not  infrequently  passing  states  of  depres- 
sion are  developed.     The  patients  are  dispirited  and  dejected, 

'  Hecker,  Virchows  Archiv  Hi.  394. 

-  Daraszkiewicz,  Uber  Hebephrenic,  insbesonderc  deren  schwere  Form.  Diss. 
Dorpat,  1892. 


CLINICAL  FORMS  95 

they  think  they  are  syphilitic,  have  got  the  itch  or  dyspepsia  ; 
they  have  a  feeHng  of  oppression  in  their  brain  ;  they  search 
out  all  possible  physicians  and  quacks ;  the  disease  is  in  all 
their  limbs.  Their  morbid  sensations  sometimes  assume  the 
most  nonsensical  forms.  They  have  no  brain  any  longer  ; 
their  back  is  broken  in  two  ;  their  blood  has  been  taken  from 
them  ;  their  body  has  died  ;  their  legs  are  exchanged.  A 
female  patient  thought  that  she  had  the  Kaiser  in  her 
stomach,  every  human  being  in  her  body,  a  telephone,  small 
dolls,  a  bicycle  in  her  head,  that  she  had  a  wooden  head  ; 
five  people  had  been  made  out  of  her.  Other  patients  become 
anxious,  are  to  blame  for  everything,  are  damned,  have  com- 
mitted sins,  are  said  to  have  killed  someone ;  they  wish  to 
make  confession,  read  the  Bible  zealously,  search  out  clerg)'- 
men.  People  are  looking  at  them,  speaking  about  them, 
making  fun  of  them,  hatching  out  abominable  crimes,  are 
persecuting  them,  are  selling  them  for  immoral  purposes,  are 
hypnotising  them,  are  making  fools  of  them.  Little  girls 
make  sexual  assaults  on  them  ;  everywhere  there  are  enemies, 
"  enchanters,"  conspirators ;  it  is  a  year  of  revolution,  a 
hereditary  feud ;  the  arch-enemy  has  a  hand  in  it.  Stuff  is 
blown  into  the  spinal  marrow  of  the  patient ;  his  nature  is 
electrically  withdrawn  from  him ;  his  forehead  is  bent  in ; 
people  blow  up  his  testicles,  cut  his  boots  to  pieces,  give  him 
poison  in  his  food,  assault  him  at  night,  mutilate  him ;  he 
gets  a  headache  if  he  enters  a  church.  He  must  be  slaughtered, 
he  is  taken  prisoner,  stamped  to  pieces,  "  sawn  asunder  and 
broken  on  the  wheel."  His  wife  is  unfaithful,  has  secret 
intercourse  with  two  other  men,  wishes  to  poison  him. 
Thoughts  of  suicide  often  rise  to  the  surface ;  a  patient 
thought  he  would  have  liked  to  kill  his  child  in  order  that 
it  might  not  be  so  unhappy  as  himself. 

Exalted  Ideas. — On  the  other  hand  we  meet  also,  but  in 
smaller  range  with  exalted  ideas.  The  patient  feels  that  he 
has  a  special  call,  is  something  more  than  everyone  else,  has  a 
proud  spirit,  an  enormous  will-power,  is  "the  ornament  of  his 
feelings,"  is  sent  from  God,  will  be  Christ,  receives  revelations  ; 
the  feast  of  the  atonement  is  there.  He  is  Maurice  Monfort 
of  Scotland,  is  surrounded  with  princes  and  emperors,  is  des- 
cended from  his  grandfather  Billbull,  has  10-20,000  marks 
capital,  will  be  a  rich  man  ;  the  hospital  belongs  to  him.  He 
will  attain  to  great  things,  will  make  a  fortune  by  national 
bankruptcy  ;  he  will  have  permission  given  him  to  carry  on  a 
temperance  restaurant,  and  then  he  will  dispense  wine,  beer, 
and  brandy.  A  patient  hoped  to  become  "a  general  with 
250  marks  yearly  income";  a  female  patient  thought  that  she 


96  DEMENTIA  PRECOX 

was  divorced  and  had  children  by  a  captain  in  the  army ; 
another  declared  that  she  was  the  Empress  Augusta.  Many 
patients  do  not  acknowledge  their  father  any  longer,  they 
speak  of  their  "  so-called  parents." 

At  the  time  the  patients  are  giving  utterance  to  these 
nonsensical  delusions  they  are  for  the  most  part  fairly  quiet 
and  quite  sensible,  clear  about  time  and  place,  about  their 
surroundings  and  their  affairs,  but  incoherent  and  desultory 
in  their  train  of  ideas  ;  they  are  not  in  a  position  to  occupy 
themselves  seriously  and  with  perseverance  in  mental  work  ; 
they  are  childishly  incapable  of  making  a  decision  and 
susceptible  to  influence.  Their  delusions  even  appear  mostly 
only  as  sudden  thoughts,  which  are  not  further  worked  up  or 
retained.  Memory,  especially  what  was  learned  at  school, 
and  the  recollection  of  recent  events  may  be  quite  undisturbed. 

Emotions. — These  are  for  the  most  part  in  harmony  with 
the  ideas  to  which  the  patients  give  utterance,  but  are  not 
very  deep  and  they  show  quite  sudden  fluctuations.  The 
patients  laugh  and  weep  without  recognisable  cause,  some- 
times convulsively,  fall  abruptly  into  violent  excitement,  but 
quieten  down  again  just  as  suddenly.  Sometimes  there  pre- 
dominates an  imperturbably  exalted,  self-satisfied  mood  ;  in 
other  patients,  a  childish  hilarity  which  passes  easily  into  a 
lachrymose  state  or  a  pitiable  faint-heartedness ;  or  the 
patients  are  mistrustful,  peevish,  impertinent,  rough  and  rude, 
break  out  into  obscene  abuse  on  the  most  insignificant 
occasions,  threaten  and  become  violent.  A  patient  without 
more  ado  shot  a  railway  employee  with  whom  he  had  fallen 
into  an  altercation.  A  few  patients  incline  to  exaggerated 
leligiosity ;  a  patient  wished  to  change  his  religion  ;  others 
plan  to  go  into  a  cloister.  Many  are  sexually  excited,  plan  to 
be  married  ;  show  a  "  pathetic  desire  for  love,"  masturbate, 
expose  themselves,  make  sexual  assaults  on  little  girls ;  a 
patient  wished  to  go  to  bed  with  his  mother  and  sister. 
Women  put  matrimonial  advertisements  into  the  newspapers, 
"  scream  for  a  husband,"  give  themselves  without  regard  to 
anyone,  let  whole  troops  of  young  men  on  the  highway  misuse 
them,  and  fall  into  prostitution. 

Conduct- — The  disease  makes  itself  noticeable  in  by  far 
the  most  striking  way  in  the  activities  of  the  patients.  Already 
in  the  beginning  of  the  rnalady  a  change  in  their  behaviour 
invariably  sets  in.  They  become  dreamy,  shy  of  their  fellow- 
beings,  withdraw  themselves,  shut  themselves  up,  do  not 
greet  their  friends  any  more,  stand  about  in  corners,  stare 
intently  in  front  of  them,  give  no  answer,  talk  with  themselves. 
Others  become  stubborn,  self-willed,  difficult,  insubordinate,  or 


CLINICAL  FORMS  97 

unrestrained,  restless,  loquacious.  Their  capacity  for  work 
suffers  severely.  They  do  not  trouble  themselves  any  more 
about  their  obligations,  do  everything  the  wrong  way  about ; 
a  patient  cleaned  his  boots  with  mud.  They  leave  everything 
where  it  is,  suddenly  throw  the  shovel  away,  go  to  bed,  look 
out  at  the  window  all  day  long,  busy  themselves  with  trifling 
affairs,  make  wreaths  of  flowers ;  they  exert  themselves  to 
learn  poems  off  by  heart,  or  to  begin  Latin  ;  a  patient  said 
"  he  took  as  great  pains  as  possible  to  investigate  thoroughly 
what  the  real  meaning  of  positive  and  negative  electricity 
was."  Many  patients  stop  working,  because  they  have  enough 
to  live  on  ;  others  l^ecause  of  their  performances  being  of  less 
value,  work  "  for  board "  without  wages  ;  they  frequently 
chafige  their  situations  because  they  are  of  no  use  anywhere. 
One  of  my  patients  suddenly  appeared  unasked  at  the  house 
of  strangers  with  a  stolen  manure-fork  in  order  to  spread 
manure  ;  another  time  when  he'again  escaped  he  joined  some 
workmen  and  unloaded  stones  with  them,  then  went  to  a 
strange  stable  and  began  there  to  saw  wood.  A  few  patients 
have  in  view  to  change  their  occupation.  A  patient  who  till 
then  had  wished  to  study  theology,  decided  to  study 
medicine  because  theology  was  ^  too  stupid  "  for  him,  another 
planned  to  go  on  the  stage,  a  third  who  had  never  shown 
any  musical  inclinations  wished  to .  study  the  theory  of 
music  ;  a  fourth  patient  wished  for  himself  "  a  little  post  in 
the  hospital." 

The  whole  conduct  of  life  of  the  patients  becomes  senseless 
and  incoherent.  They  cannot  any  longer  manage  money ; 
they  make  aimless  purchases,  give  away  and  squander  their 
property ;  a  female  patient  threw  good  fruit  to  the  pigs.  A 
poor  patient  fooled  away  an  inheritance  of  5000  marks 
within  two  years;  another  stopped  taking  money  for  the 
wares  which  he  sold.  Many  patients  fall  into  drinking 
habits  and  in  this  way  come  down  in  the  world  with  remark- 
able rapidity.  In  their  outer  appearance  they  become  dis- 
orderly, negligent,  dirty,  peculiar.  They  do  not  wash  them- 
selves any  more  ;  they  wear  conspicuous  clothing,  tie  cigar 
ribbons  in  their  button-hole,  stick  paper  in  their  ears  ;  a 
patient  put  on  a  truss  without  any  reason ;  a  lawyer  bound 
flowers  on  to  his  stick  and  umbrella,  hung  a  garland  round 
his  neck,  stuck  brooches  and  pictures  on  himself,  blackened 
his  face,  painted  a  large  paragraph  sign  on  his  coat. 

With  these  are  associated  a  multitude  of  incomprehensible 
and  childishly  aimless  actions.  The  patients  throw  stones, 
lie  down  in  cruciform  attitude  on  the  floor,  cut  off  their  hair, 
undress,  bathe  publicly  in  the  middle  of  the  town,  begin  to 

G 


98  DEMENTIA  PR/ECOX 

play  the  harmonica  at  night,  run  a&out  on  the  rails  of  the 
shunting-station,  burn  their  own  hair  and  beard  and  those  of 
other  people  with  their  cigar,  cut  up  their  linen  and  clothing  ; 
they  destroy  the  furniture  and  throw  it  about  ;  they  lie 
sprawling  on  the  floor,  turn  somersaults  in  bed,  climb  on  to 
the  stove,  slide  about  the  room  with  chairs.  A  patient 
smashed  a  crucifix  and  a  gravestone ;  a  second  tolled  the 
big  bell  during  divine  service ;  a  third  lit  the  candles  on  the 
high  altar  and  imitated  the  clergyman,  a  fourth  lay  down  in 
a  fountain.  A  teacher  played  tag  with  his  scholars,  lay 
down  in  a  crib  in  the  cow-house  "  from  love  of  mischief," 
put  his  head  into  the  well,  because  on  account  of  his  great 
sins  he  could  do  very  well  with  another  baptism,  lay  down 
on  the  floor  in  order  to  measure  how  long  his  coffin  wt)uld 
have  to  be ;  a  lady  fed  her  dolls  with  coffee.  A  female 
patient  abused  herself  grossly  with  the  strongest  expressions, 
others  try  to  throttle  themselves,  to  cut  their  throat,  to  cut 
off"  their  fingers,  usually  without  special  energy,  often  in  full 
publicity.  A  patient  asked  for  gunpowder  ;  another  scratched 
himself  with  his  knife  in  order  to  lessen  the  influences  ;  a 
female  patient  wished  that  her  body  should  be  cut  up. 

Very  frequently  we  observe  ifi  the  patients  a  certain 
restlessness.  They  run  away  suddenly  from  their  work, 
roam  about,  wade  barefoot  in  the  snow,-  insist  on  going 
out  even  at  night,  become  deserters,  hide  themselves  away, 
make  senseless  journeys,  often  without  money  and  without 
a  ticket,  want  to  get  into  the  Castle,  to  go  to  America  ;  a 
patient  wandered  for  days  in  the  forest  without  food.  In 
-consequence  of  this  they  easily  become  vagrants,  beg,  commit 
small  thefts,  and  land  in  this  way  in  prison  and  the  work- 
house, where  then  a  deterioration  of  their  condition  often  sets 
in  ;  nearly  a  quarter  of  my  male  patients  met  this  fate. 

The  conduct  of  the  patients  invariably  shows  many 
peculiarities.  They  are  very  changeable  in  their  behaviour, 
sometimes  accessible,  childlike,  docile,  at  other  times  repellent, 
inapproachable,  resistive,  irritable,  flaring  up  easily,  at  One 
moment  loquacious  and  verbose,  at  another  taciturn  and 
mute.  Their  mode  of  speech  is  frequently  manneristic, 
unctuous,  didactic,  sometimes  noisy  or  purposely  obscene. 
The  substance  of  their  conversation  is  often  confused  and 
unintelligible,  or  there  is  nothing  in  it.  Frequently  they  ride 
to  death  certain  phrases ;  they  indulge  in  stale  jokes  and 
insipid  doggerel  ;  they  introduce  unusual  or  foreign  expres- 
sions or  dialect.  Many  patients  startle  us  by  extraordinary 
turns  of  expression  and  abrupt  nonsensical  questions ;  a 
patient  said,  "  He  blows  his  nose,  and   I   blow  mine  ;  who 


CLINICAL  FORMS  99 

then  is  right,  I  or  he  ? "     Others  have  a  tendency  to  foolish 
plays  on  words  and  to,  peculiar  symbolism. 

Writing. — These  peculiarities  often  appear  more  distinctly 
in  the  writing  of  the  patients  which  are  usually  in  "  Karlchen- 
Miesnik-style,"  according  to  Hecker's  description.  Besides 
negligent  want  of  connection  in  the  train  of  thought,  repeated 
change  of  construction  in  long  spun-out  periods^  mixed 
metaphors^  abrupt  interspersing  of  sudden  ideas,  rhymed 
effusions,  we  find  a  slovenly  external  form,  irregular  hand- 
writing, flourishes  on  single  letters,  underlining,  deficiency  or 
superfluity  in  marks  of  punctuation,  and  monotonous  contents 
often  with  verbal  repetitions.  An  example  is  given  in 
the  following  extract  from  a  letter  written  by  a  student  who 
was  up  for  his  leaving  examinations.  The  extract  forms 
the  introduction  to  the  specimen  of  writing  4  which  -is 
reproduced  here  -.— 

"When  you  on  the  19th  May  of  this  year,  namely  on  a  beautiful  Sunday 
afternoon,  constructed  the  plan  for  yourself  to  do  nie  the  honour  to  visit 
me  by  the  railway  in  the  Hospital  for  the  Insane  at  H.,  care  of  Professor 
K.,  Littera  Voss-strasse  Nr  4,  you  thought  then  perhaps  to  give  your  dear 
and  good  son  a  special  pleasure,  visiting  him  in  the  institution  I — Or  was 
it  not  so?  I — When  I  further  recapitulate  again  the  many  unjust  things 
and  abusive  epithets  which  I  threw  at  the  head  of  my  dear  mama,  I 
think  that  I  really  cannot  avoid  being  obliged  to  confess  that  I  should 
have  rather  expected  a  visit  first  from  the  maternal  side.  Supposing 
namely  the  case  that  the  above  mentioned  should  not  only  have  been  ill, 
but  had  actually  been  so,  so  would  my  humble  self  have  first  strongly 
advised  in  her  case  a  visit  to  her  first-born  !  Now  as  happily  my 
22nd  birthday  coincided  with  Ascension  day,  as  God  and  fate  would 
have  it,  but  in  the  Asylum,  the  visit  of  my  mother  in  person  certainly 
caused  me  a  great  momentary  joy,  especially  as  she  from  motherly 
love  showed  me  the  honour  and  kindness  to  promise  to  bring  me  another 
cake  and  a  silver  chain,  but  in  any  case  her  visit  would  not  and  could  not 
be  a  visible  comfort  for  me  for  the  old  reason,  namely  my  father's 
dissatisfaction  with  my  diligence  at  home,  regarding  conscientiousness  ! 
Further  I  thank  you  also  most  heartily  for  the  beautiful  artistic  card  with 
the  special  signature  Family  G.  But  wait  !  Who  should  the  Family  G. 
be  then  in  this  case,  if  its  principal  member  is  crouching  in  a  madhouse  ?  " 
and  so  on. 

The  shallowness  of  the  contents,  the  incomprehensibility, 
the  laboured  style,  the  incoherence  of  the  train  of  thought,  as 
well  as  the  slovenly  external  form,  which  is  scarcely  decipher- 
able on  account  of  the  many  crossings-out  and  alterations,  all 
these  features  of  the  specimen  of  writing  appended  here  show 
the  profound  mental  incapacity,  which  is  in  sharp  contra- 
diction to  the  cultural  standing  of  the  patient  who  was 
originally  highly  gifted.  For  comparison,  I  place  beside  it 
a  letter  very  similar  as  regards  -handwriting,  written  by  a 
day-labourer    likewise    hebephrenic.      The    letter    is    better 


lOO 


DEMKNTIA  PRECOX 


//J  «/^ 


-t-'^tA^i 


/!• 


S-^T^^x^ 


r 


'..^ 


^*^     ^C^A^f-v^     _    ^y^^/l^i^i^^    ^'•^'Jfl/^^V^^^-iv^^tt-^^^-t^**^ 


^«'^€?/,i^      *t>-t-'i^  < 


/a 


Specimen  of  writing  4.     Letter  of  »  Hebephrenic. 


CLINICAL  FORMS  loi 

arranged  in  external  form,  but  the  contents  are  still  .more 
incoherent.  The  abrupt  breaking- off  of  the  ideas,  the 
vacuity  of  thought,  the  meaningless  expressions  of  speech 
are  accompanied  here  by  a  certain  feeling  of  disease  : — 

"Dear  parents  and  brothers  and  sisters,  Do  not  be  anxious  about  me, 
my  thoughts  are  directed  in  the  right  way,  I  hope  you  will  not  experience 
that  again.  I  am  convinced  that  you  meant  well  with  me  and  still 
mean  well.  Social  relations  make  it  necessary  to  pay  taxes.  To  live 
and  let  live  is  the  main  principle  of  the  purely  human  thought  especially 
of  a  day-labourer  as  I  am.  The  arrival  has  done  me  good  ;  but  I  am 
somewhat  weak  in  my  nerves.  I  shall  take  pains  to  direct  my  thoughts 
wholly  according  to  the  nat.  liberal  circumstances,  not  socialist.  I  am 
also  no  longer  so  melancholy,  have  lost  m  knowledge  terribly. 

In  the  following  extract  from  a  letter  of  a  young  business 
man  the  feeling  of  disease  also  appears  distinctly  along  with 
the  peculiarity  of  expression  : — 

"There  is  no  prospect  that  an  after-eflfect  event,  of  my  symptoms 
come  to  a  decision,  but  it  is  certain  that  the  contained  sensations  unfold 
their  arrangement.  ...  As  regards  my  condition,  end-symptoms  of 
epileptic  combination  show  themselves  and  I  am  always  prepared,  if  that 
should  come,  which  I  did  not  expect.  The  depressive  phenomena 
corresponding  to  subj.  psych,  neurasthenic  combination  are  of  a 
permanent  kind  and  now  you  will  perhaps  yourself  know  what  is 
impending.  .  .  .  With  my  psychological  and  psychiatric  studies  also  will 
it  now  soon  be  done,  for  my  condition  is  itself  composed  of  psychiatry 

Another  patient,  who  afterwards  became  drivellingly 
demented,  wrote  to  a  married  woman  in  a  lengthy  document 
from  the  "  madhouse  H."  a  declaration  of  love  in  German, 
English,  French,  and  Greek  with  the  assurance,  that  he  had 
to  .get  air  for  his  oppressed  heart,  and  must  explain  what  he 
could  not  keep  any  longer  for  himself  alone  without  being 
obliged  to  fear  that  he  would  get  palpitation  or  that  his 
senses  would  take  a  different  direction  from  that  which 
nature  had  traced  out  for  them.  A  young  student  of 
divinity  composed  the  following  poem,  in  which  the  vacuity 
of  the  jingle  of  words  as  well  as  the  loss  of  artistic  feeling 
comes  very  clearly  to  expression  : — 

Ferner  Lander  Stadte  hab'  ich  viel  gesehen, 
,        Wunderbar  gebaut  und  riesengross, 

Und  es  herrschte  drin  ein  eigenartig  Wehen, 

Barg  manch'  siiss  Geheimnis  in  dem  Schoss. 

Und  die  Ratsel  blieben  ungeldst, 

Hatte  nicht  die  Liebste  heimlich  mir  verraten, 

Was  uns  anzieht,  was  uns  von  sich  stosst, 

Und  dies  alles  bei  dem  besten  Wein  und  Braten. 

The  bearmg  of  the  patients  is  often  constrained,  forced, 
affected,   or    slack    and    negligent,   "not    military,"   as    was 


I02  DEMENTIA  PRECOX 

ascertained  in  the  case  of  a  soldier;  they  frequently  also 
commit  breaches  of  military  discipline,  laugh  in  the  ranks, 
do  not  stand  erect.  They  make  faces,  assume  peculiar 
attitudes,  lie  on  their  faces,  make  strange  gestures,  scratch 
themselves  till  the  blood  comes,  spit,  are  occasionally  filthy, 
produce  nonsensical  drawings  and  needlework.  Not 
infrequently  automatic  obedience,  especially  catalepsy,  can 
be  demonstrated. 

The  sleep  of  the  patients  is  frequently  disturbed,  some- 
times by  excitement  at  night.  The  appetite  is  irregular  ;  the 
patients  are  sometimes  voracious;  at  other  times  they  eat 
nothing  or  only  certain  articles  of  food,  cram  them  hastily 
into  their  mouth,  eat  in  an  extremely  unmannerly  way, 
seize  the  food  with  their  hands.  A  patient  declined  food, 
giving  as  his  motive  that  he  lived  on  the  supernatural ; 
another  asked  for  better  food  and  at  the  same  time  called 
out :  "  Waiter,  a  glass  of  water  !  " 

The  Further  Course  of  the  disease  in  the  very  great 
majority  of  cases  which  I  have  brought  together  led  to 
profound  dementia  in  which  for  the  most  part  the  peculiarities 
of  the  previous  morbid  condition,  silly  conduct  and  in- 
coherence of  the  train  of  thought,  were  still  distinctly 
recognisable.  In  a  quarter  of  the  cases  the  patients  became 
wholly  dull  and  devoid  of  thought,  in  a  further  number  ot 
cases  manneristic  or  negativistic.  Only  in  about  12  per  cent, 
of  the  observed  cases  the  disorders  disappeared  so  far  that  a 
simple  weak-mindedness  remained  without  other  striking 
morbid  phenomena.  Improvement  lasting  somewhat  longer, 
8  or  10  years,  with  later  relapse,  was  ascertained  in  about 
7  per  cent,  of  the  cases.  Not  infrequently  the  condition 
exhibited  fluctuations,  sometimes  within  a  fairly  regular 
return,  it  may  be  in  connection  with  the  menses.  As  the 
issue  in  states  of  slight  weakness  was  noted  in  about  19  per 
cent,  of  the  total  number  of  our  cases  of  dementia  praecox, 
and  considerable  and  more  lasting  improvement  occurred  in 
nearly  26  per  cent,  of  the  cases,  we  must  regard  silly  dementia 
as  an  unfavourable  form  of  the  disease.  It  includes  about 
13  per  cent,  of  our  observed  cases.  Seizures,  in  nearly  21  per 
cent.,  appear  to  be  a  little  more  frequent  than  in  the  average. 
The  age  of  the  patient  corresponds  fairly  accurately  with 
that  of  dementia  praecox  as  a  whole ;  59  per  cent,  of  the 
patients  had  not  yet  reached  their  25th  year ;  the  male  sex 
was  represented  by  63  per  cent.,  which  is  considerably  more 
than  the  average  (56  per  cent.) 


CLINICAL  FORMS  .103 

Simple  Depressive  Dementia. 

As  the  third  group  of  dementia  praecox  I  should  like  to 
take  together  under  the  name  of  simple  depressive  or 
stuporous  dementia,  those  cases  in  which  after  an  introductory 
state  of  depression  with  or  without  phenomena  of  stupor  a 
definite  psychic  decline  gradually  develops.  The  beginning 
of  the  disease  is  in  something  more  than  half  of  the  cases 
slowly  progressive;  still  in  nearly  20  per  cent,  it  is  acute, 
especially  in  the  forms  in  which  there  is  stupor.  Sometimes 
for  a  number  of  years  before  the  actual  onset  of  the  disease 
there  is  a  history  of  a  quiet,  shy,  depressed  behaviour.  The 
introductory  phenomena  are  those  already  described — head- 
aches, vertigo,  disorders  of  sleep,  failing  appetite,  great  need 
for  rest,  now  and  then  fainting  fits,  hysteriforrh  or  epileptiform 
seizures.  The  patients  stop  working,  neglect  the  household, 
go  to  bed,  withdraw  themselves,  stare  into  a  hole,  are 
continually  brooding,  run  away,  hide  themselves,  carry  on 
confused  conversations. 

Hallucinations. — Not  infrequently  hallucinations  appear, 
although  they  do  not  usually  take  up  much  room  in  the 
clinical  picture.  The  patients  see  the  Virgin  Mary  on  the 
ceiling,  heavenly  apparitions,  God  and  the  devil,  mice ;  they 
hear  people  gossiping,  spirits  making  a  noise,  the  voice  of 
their  father  or  of  their  neighbour,  of  the  "  men  from  the 
churchyard,"  of  the  "tormentors  from  above  downwards,"  of 
the  maidens ;  their  companions  are  jeering.  Reproaches  are 
made  to  them  and  commands  bestowed  on  them,  thoughts 
are  given  to  them  which  must  be  repeated.  "  The  voices 
work  the  system  of  thought  and  breath,"  said  a  female 
patient ;  she  heard  that  she  was  damned,  that  she  was  no 
longer  pure,  that  she  was  to  be  hacked  to  pieces.  To  other 
patients  eating  is  forbidden;  "that  has  crept  in  so  for  the 
last  five  or  six  years,"  said  a  patient.  The  feeling  of  sexual 
or  hypnotic  influence  also  occurs. 

Depression. — As  a  rule  all  sorts  of  depressive  ideas 
appear  on  the  surface,  especially  those  of  hypochondriacal 
content.  .  The  patient  suffers  from  all  possible  diseases,  from 
softening  of  the  brain,  is  weak  in  his  head,  ill  in  his  nerves, 
has  foul  blood,  has  contracted  atrophy  of  the  nerves  by 
onanism,  has  lost  his  reason ;  one  half  of  his  body  is  already 
gone ;  he  never  has  his  life.  His  sense  is  torn  asunder,  his 
body  is  melted  up,  his  heart  is  worn  out ;  "  reason,  under- 
standing, cind  sense  have  gone  out  of  my  brain,"  said  a  female 
patient;  another  asserted  that  he  had  "the  half  exhalation 
of  a  woman."     The  following  extracts  from  a  comprehensive 


I04  DEMENTIA  PRECOX 

description  of  himself  written  by  a  patient  who  was  perma- 
nently quite  sensible  and  reasonable,  may  give  an  idea  of 
these  hypochondriacal  trains  of  thought  which  gradually 
develop  alongside  of  the  most  various  hallucinations  and 
dysaesthesict : — 

"Already  in  June  very  great  excitement  became  noticeable  in  me. 
.  .  .  Remarks  about  me  could  excite  me  in  the  highest  degree.  In 
studying  I  began  sometimes  at  one  place,  sometimes  at  another  .  .  .  ;  in 
writing  I  then  very  often  made  mistakes,  i  .  .  All  at  once  it  happened  to 
ine  that  studying  was  no  longer  at  all  possible  ;  the  sentence  that  had 
been  read  shortly  before  did  not  slick.-  In  a  rather  long  excerpt,  which 
I  had  already  begun,  I  noticed  a  considerable  change  in  my  handwriting, 
and  that  the  handwriting  changed  in  the  course  of  the  copying  of  a  few 
pages.  I  carried  on  my  studies  in  a  most  extraordinary  hurried  way, 
and  did  not  allow  myself  any  more  the  necessary  rest  and  recreation  ;  I 
was  unwilling  to  take  any  more  the  necessary  time  even  for  eating.  .  .  .  My 
memory  left  much  to  be  desired  already  for  a  considerable  time.  .  .  .  My 
sleep  was  bad  ;  I  could  not  fall  asleep  for  a  long  time,  and  in  the  morn- 
ing I  was  not  properly  strengthened  and  refreshed.  .  .  .  Physically  I 
became  gradually  weaker  ;  the  skin  of  my  face  became  pale  and  was 
pasty  to  the  touch.  I  constantly  had  the  inclination  to  look  in  the  mirror. 
I  saw  that  my  eyes  had  a  peculiarly  dull  lustre.  If  I  turned  my  head 
quickly,  immediately  a  peculiar  cracking  was  heard.  I  was  struck  by 
the  rapid  diminution  of  my  visual  power,  in  spite  of  the  fact  that  I  spared 
my  eyes.  ...  I  had  accustomed  myself  for  a  long  time  when  I  went  a 
walk  to  wend  my  steps  where  I  had  the  prospect  of  meeting  only  a  few 
people.  ...  I  ^\d  not  trust  myself  any  longer  to  look  at  people.  .  .  . 
Later  I  then  began  to  have  a  certain  fear  of  everything ;  I  did  not  trust 
myself  any  longer  to  look  at  anything,  and  thought  that  enjoyment,  of 
nature  was  also  forbidden  to  me  ;  ideas,  as  if  I  dared  not  any  more 
touch  myself  or  look  at  myself,  came  to  me  occasionally.  When  I  then, 
under-  medical  treatment,  took  bromides,  I  got  curious  pricking  sensa- 
tions in  my  brain.  In  walking  I  thought  that  the  right  leg  was  thrown 
out  in  front  of  me,  sometimes  also  the  left  leg.  .  .  .  Till  sleep  came  over 
me  I  had  a  sensation  in  my  legs  as  if  they  were  squeezed  firmly  and  as  if 
the  skin  were  contracted  on  the  shin  bones  and  feet.  On  the  left  side 
of  the  body  I  thought  a  paint  brush  was  being  stroked  downwards, 
especially  in  the  region  of  the  heart.  Often  till  I  fell  asleep  I  could  not 
get  enough  breath  ;  I  had  the  feeling  as  if  it  always  drove  the  belly 
higher  up,  and  as  if  there  were  an  impediment  against  the  breastbone  in 
my  breast,  so  that  my  breast  could  not  sink  any  more.  In  my  head  I 
thought  balls  rolled  up  and  then  fell  down.  Besides  that  I  had  also  the 
following  sensations  ;  my  skull-cup  was  like  glass  to  the  touch  and  my 
hair  like  fur  ;  my  skull  could  be  pressed  together  at  will  ;  my  head  was 
sometimes  light  and  sometimes  heavy ;  my  teeth  were  sometimes 
knocked  out,  sometimes  knocked  in.  My  tongue  was  sometimes  too 
long  for  speaking  so  that  it  came  close  against  my  teeth,  sometimes  it 
was  too  short  and  contracted.  In  my  gums  I  was  aware  of  all  kinds  of 
oppressive  and  dragging  feelings ;  my  nose  was  sometimes  knocked 
inwards,  sometimes  outwards.  There  was  sometimes  a  bad  smell  of  the 
mouth  ;  sometimes  there  was  a  fragrant  odour.  Often  also  such  a  smell 
was  blown  on  me.  Cold  air  was  blown  over  my  face.  Someone  sat 
down  beside  me  on  the  bed.  My  buttocks  were  rough  like  a  grater. 
There  were  noises  in  my  heart,  there  was  a  rubbing  as  of  two  millstones 
on  each  other.     Sometimes  I  felt  my  body  light,  sometimes  heavy.     I 


CLINICAL  FORMS  105 

thought  someone  was  sleeping  close  beside  me  and  sometimes  also  over 
me.  I  heard  loud  hammering  on  the  wall  and  whizzing  in  the  air.  The 
bedstead  sank  downwards  at  my  feet  and  rose  upwards  at  my  head,  or  it 
turned  over  sidewards.  I  flew  away,  the  bed  with  me.  The  voices  were 
often  preferable  to  these  sensations  ;  I  could  more  easily  fall  asleep  with 
the  former.  I  heard  pilgrims  pass  by  in  two  choruses  ;  the  one  said  : 
'He  must  die,'  or  'He  is  dying';  the  other:  'He  is  becoming  again.' 
First  I  heard  the  great  bell  ring,  then  small  bells,  then  great  and  small 
•confusedly.  When  reading  I  was  disturbed  by  a  voice  on  my  left  which 
read  quickly  along  with  me  in  an  unpleasant  way.  .  .  .  The  back  of  my 
head  appeared  to  me,  when  I  laid  it  on  the  pillow,  all  wobbling  and  soft. 
At  and  in  my  head  I  had  the  following  sensations : — pricking  above, 
squirting  from  my  hair,  the  falling  down  of  big  drops  out  of  my  head  on 
to  the  pillow.  Besides  that,  I  often  thought  that  drops  were  falling  on 
the  bedcover  or  on  the  sleeve  of  my  night-shirt,  on  the  back  of  my  hand, 
on  my  finger-nails.  ...  I  saw  people  with  two  shadows  in  place  of  eyes, 
then  blind  :  then  again  I  thought  they  had  scintillating  fire  in  their  eyes  ; 
once  only  for  a  short  time  I  saw  people  black  in  the  face.  ...  I  had  a 
feeling  as  if  a  worm  would  creep  around  in  my  brain  ;  then  would  creep 
through  my  gums  and  tongue  into  my  spinal  marrow  ;  in  my  neck  I  felt 
crackling  crashing  noises.  ...  I  heard  the  following  voices  :  '  Nothing 
rare,'  '  Nothing  special,'  '  Carrion,'  '  Rascal,'  '  Onanist,'  and  especially  in 
the  last  part  of  the  time  nothing  but  my  name." 

The  patient  who  while  suffering  from  the  phenomena 
described  was  slowly  becoming  weak-minded,  not  only 
observed  himself  most  accurately  but  .  also  recognised 
quite  clearly  the  morbidity  of  the  disorders  reported  by 
himself;  the  remarkable  point  in  his  case  was  only  the 
equanimity  with  which  he  reproduced  all  his  tormenting 
perceptions. 

Ideas  of  Sin  and  of  Persecution. — Not  infrequently  ideas 
•of  sin  also  appear,  and  in  connection  with  them  ideas  of 
persecution.  The  patient  has  sworn  falsely,  committed  a 
mortal  sin,  is  a  "  sinful  serpent,"  is  accused  of  sodomy,  wants 
to  die.  He  must  atone,  be  sacrificed,  has  fallen  into  the 
hands  of  the  evil  one  who  is  now  going  to  wring  his  neck. 
He  is  shut  out  from  society,  is  afraid  of  an  assault  by  night ; 
people  are  not  kind  to  him.  He  is  watched,  is  going  to  be 
fetched,  is  to  be  dragged  away  in  the  knacker's  cart,  is  to 
be  beheaded,  is  to  be  killed  by  a  painful  death.  His  food 
is  filthy,  contains  poison.  Often  these  ideas  are  very  in- 
distinct and  obscure  and  only  find  utterance  on  questioning. 
Here  and  there  an  exalted  idea  is  also  perhaps  on  an 
.  occasion  brought  forward ;  the  patient  is  a  substituted  child, 
must  strive  after  something  higher,  must  meet  with  Kaiser 
and  Kings,  is  in  Paradise.  The  patient,  from  whom  the 
above  description  of  himself  came,  thought  some  years  later 
that  he  would  quite  likely  yet  become  a  professor. 

Perception  usually  exhibits  at  first  no  very  serious 
disorders,  yet  the  patients  are  for  the  most  part  inattentive. 


io6  DEMENTIA  PRECOX 

indififerent,  often  also  repellent,  melancholy.  People  and 
surroundings  are  as  a  rule  correctly  recognised,  while  the 
patients  are  often  not  clear  about  time-relations.  The  train 
of  thought  of  the  patients  changes  abruptly,  is  at  times 
confused,  is  easily  diverted.  Memory,  acquired  knowledge 
and  expertness  remain  sometimes  fairly  well  preserved, 
sometimes  they  undergo  considerable  loss.  Soonei:  or  later, 
however,  a  certain  mental  decay  makes  itself  felt ;  the 
patients  become  poor  in  ideas  and  weak  in  judgment ;  "  I 
often  don't  know  at  all  what  is  the  matter  with  me,"  said  a 
patient.  The  relatives  of  a  female  patient  declared,  "  She 
couldn't  think  rightly  and  did  not  know  what  she  was 
talking  about." 

Mood  is  in  the  beginning  usually  anxious,  dejected, 
lachrymose  and  despondent ;  the  patients  have  no  more  joy 
in  life,  are  about  to  despair,  do  not  trust  themselves  ;  they 
weep  and  lament,  would  like  to  die  because  things  do  not 
please  them  any  more.  They  frequently  make  attempts  at 
suicide,  often  in  very  nonsensical  ways.  They  try  to  throw 
themselves  out  at  the  window,  dash  their  head  against  a 
wall,  go  into  a  stream  to  turn  back  again  immediately,  run 
into  the  forest  to  let  themselves  freeze  to  death  there.  A 
female  patient  drank  petroleum  ;  a  patient  hung  his  head 
out  of  the  bed  in  order  that  it  could  be  hewn  off.  Some- 
times periods  of  exalted  and  even  unrestrained  mood 
temporarily  intervene.  Other  patients  are  irritable,  morose, 
violent.  Sexual  excitement  vents  itself  in  impulsive  mas- 
turbation and  in  sexual  intercourse  regardless  of  consequences  ; 
a  patient  made  a  proposal  of  marriage  to  a  lady  who  was 
wholly  unknown  to  him.  In  the  further  course,  however, 
often  very  soon,  the  emotional  life  becomes  duller  \  the 
participation  of  the  patients  in  the  events  around  them 
becomes  always  feebler.  They  do  not  trouble  themselves 
about  their  fellow-patients,  remain  indifferent  to  exciting 
events,  do  not  move  a  muscle  if  one  occupies  himself  with 
them  or  even  causes  them  pain.  At  the  same  time  they  • 
become  dirty,  spit  into  the  dishes  used  for  food,  smear 
themselves  with  urine,  play  with  lumps  of  fneces,  make 
messes. 

Volition. — In  the  whole  conduct  of  the  patients  the 
devastation  of  their  will  makes  itself  conspicuous  above 
everything.  They  are  tired,  weak,  lazy,  without  initiative, 
irresolute,  let  themselves  become  destitute,  live  carelessly  a 
day  at  a  time,  fling  away  money  and  pos.sessions  senselessly, 
let  themselves  drift  according  to  chance  influences  and  there- 
fore come  quickly  down  in  the  world  especially  when  they 


CLINICAL  FORMS  io; 

begin  to  drink.  Many  become  vagrants,  as  an  elementary 
school-teacher  did  in  my  observation  who  gradually  had 
•become  unfit  tor  his  calling.  Occasionally  the  stupidity  and 
irritability  of  the"  patients  lead  to  very  risky  actions.  A 
female  patient  did  not  turn  off  the  gas ;  a  patient  threatened 
his  wife  with  his  knife ;  another  bought  a  revolver  to  defend 
himself.  Many  patients  must  be  washed  and  dressed  like 
children.  Very  frequently  automatic  obedience  can  be 
demonstrated  in  them. 

Besides  this  weakness  of  will  there  is  often  a  certain 
restlessness;  the  patients  change  their  calling  and  situation, 
run  away,  make  aimless  journeys ;  a  patient  sailed  three 
times  to  America  and  back.  To  that  may  be  added  all 
kinds  of  impulsive  actions.  The  patients  speak  away  to 
themselves,  collect  everything  possible  in  their  pockets,  play 
the  piano  all  day,  scream  suddenly  for  hours,  force  their 
way  out  howling,  pray,  sing,  laugh  uncontrollably,  become 
violent  without  cause,  slide  about  on  the  floor,  climb  up  on 
to  the  windows.  Stereotyped  movements  also  occur,  rhyth- 
mical movements  of  the  body,  odd  movements  of  arm  and 
finger,  wringing  of  the  hands,  picking  and  pulling  the  fingers, 
running  up  and  down.  A  patient  always  squeezed  his 
urethra  together;  another  squeezed  his  forearm  continually 
with  his  fingers  spread  out.  He  gave  the  following  account 
of  the  motives  of  his  behaviour  : — 

"  I  must  do  that  ;  if  I  do  not  lift  it  I  have  on  the  side  no  com- 
plete course,  no  inner  life  ;  it  is  just  bad  since  I  had  the  congestion, 
the  disturbance  in  the  inner  vascular  passage.  Sometimes  I  am  out- 
wardly so  animated,  so  emotional,  sometimes  again  inwardly.  My 
blood  is  always  so  unfaithful,  my  animation  is,  however,  different, 
sometimes  inward  life,  sometimes  outward  life  ;  I  feel  that  so.  I  am 
just  weak  in  my  nerves,  weak  and  weakened  in  my  whole  body  ;  I 
must  do  that ;  otherwise  I  can't  hold  out.  The  drainage  through  the 
limbs  must  be  there  ;  otherwise  the  constituent  parts  could  not  circulate 
through  the  pores,  the  blood,  even  the  moisture.  I  will  yet  live  ;  I 
am  yet  a  young  being  ;  I  itiust  always  look  after  the  drainage.  ..." 

The  remaining  volitional  disorders  of  dementia  praecox 
usually  appear  also  in  more  or  less  pronounced  fashion. 
Mannerisms  show  themselves  in  making  faces,  in  whimsical 
ways  of  shaking  hands,  in  stirring  food  about,  in  parade  step 
in  marching,  in  solemn  and  affected  gestures,  in  rattling  in 
the  throat  and  smacking  movements  which  are  interpolated 
in  conversation.  Many  patients  lie  on  their  belly,  anywhere 
on  the  floor,  on  the  edge  of  the  bed,  take  up  uncomfortable 
positions,  keep  the  corner  of  the  bedcover  in  their  mouth. 
The  conversation  of  tlje  patients  is  incoherent,  sprinkled 
with  meaningless  words,  odd  phrases,  bewildering  expressions. 


io8  DEMENTIA  PRECOX 

A  patient  abruptly  approached  the  physician  and  said : 
"  Would  ask  you  for  the  divine  highness."  Many  patients 
lisp,  whisper,  speak  in  affected  High  German,  speak  Krench, 
scream  with  a  disguised  voice.  Negativism  meets  us  in  the 
unapproachable,  repellent  behaviour  of  the  patients.  They 
do  not  return  a  greeting,  do  not  look  up  when  they  are 
addressed,  give  evasive,  nonsensical  answers  or  even  none 
at  all,  stop  in  the  middle  of  a  sentence,  begin  to  speak  when 
one  turns  away.  They  draw  back  when  one  approaches 
them,  go  backwards  round  the  room,  creep  under  the  bed, 
resist  obstinately  every  regulation.  Their  deportment  is 
stiff,  rigid,  constrained  ;  their  limbs  become  stiff  at  every 
interference ;  many  patients  lie  in  bed  with  their  heads 
lifted  up,  or  sit  with  bowed  heads  and  closed  eyes.  They 
do  not  remain  in  bed,  endure  no  shirt,  stand  about  naked, 
do  not  eat  anything  or  only  eat  if  they  think  they  are 
unobserved ;  many  take  greedily  other  people's  food  or  only 
eat  standing  in  a  corner. 

These  negativistic  phenomena,  united  with  and  alternating 
with  those  of  automatic  obedience,  characterise  the  states  of 
stupor  \s\{\c\\  develop  in  rather  more  than  one-third  of  our  cases. 
These  states  follow  closely  the  introductory  sad  or  anxious  ill 
humour  after  a  shorter  or  longer  period,  and  may  be  of  very 
various  duration.  Not  infrequently  they  are  interrupted  by 
quickly  passing  states  of  excitement ;  the  patients  suddenly 
sing  a  song,  jump  out  of  bed,  have  a  fit  of  laughter. 

The  number  of  cases  brought  together  in  this  group 
amounts  almost  to  lo  per  cent,  of  the  cases  worked  up  here. 
As  69  per  cent,  of  the  patients  had  not  yet  passed  their  25th 
year,  we  have  here  to  do  with  a  form  which  by  preference 
attacks  young  subjects.  The  male  sex  was  represented  by 
53  per  cent,  therefore  differing  little  from  the  average,  but  it 
seemed  to  have  a  greater  share  in  the  cases  in  which  stupor 
occurred. 

The  further  course  of  the  disease  was  interrupted  in 
something  over  10  per  cent,  of  the  cases  by  improvement 
which  sometimes  continued  for  several  years ;  it  appeared 
to  me  to  be  more  frequent  in  the  stuporous  cases.  In  one 
female  patient  such  improvement  occurred  four  times  ;  re- 
lap.ses  always  of  longer  duration  followed  each  time  after 
childbirth  till  at  last  a  state  of  dementia  developed  which 
lasted  without  change  till  death  5  years  later.  As  issue  there 
was  in  27  per  cent,  of  the  cases  a  moderate  weak-mindedness 
to  be  recorded  ;  the  form  which  is  considered  here  has  there- 
fore a  substantially  more  favourajple  prognosis  than  silly 
dementia;    seizures    appeared    in     17    per    cent,   somewhat 


CLINICAL  FORMS  109 

seldomer  than  in  the  latter.  Among  the  states  of  profound 
dementia  forms  with  complete  apathy  or  with  negativistic 
features  were  the  most  frequent,  the  latter  specially  as 
termination  of  stupor. 

Delusional  Depressive  Dementia. 

Those  cases,  in  which  delusions  gain  a  considerable 
expansion  and  an  extraordinary  form,  we  take  together  as  a 
fourth  form  of  dementia  praecox,  depressive  dementia  with 
delusions.  The  beginning  of  the  disease  is  quite  similar  to 
that  of  the  last  group,  but  apparently  somewhat  more 
frequently  sttbacute.  Often  after  changes  in  the  behaviour  of 
the  patients  have  already  gone  on  for  years,  they  become 
quiet,  depressed,  anxious,  restless,  complain  of  headaches, 
giddiness,  sleeplessness,  noises  in  the  ear,  and  they  leave  off 
working  ;  a  patient  suffered  for  a  considerable  time  from 
agoraphobia. 

Hallucinations.  —  Gradually  or  suddenly  numerous 
hallucinations  now  make  their  appearance.  The  patients  see 
"horrible  pictures,"  naked  females,  three  little  men  of  the  woods, 
long  processions  of  decorated  people,  fiery  beams,  the  Mother 
of  God,  "  God,  two  lions  and  the  Kaiser,"  figures  in  heaven  ; 
angels  and  the  Virgin  Mary  offer  him  the  chalice.  A  female 
patient  saw  "  her  thoughts." 

Hallucinations  of  hearing  are  usually  the  most  strongly 
marked.  There  is  a  noise  in  the  house  ;  burglars  are  forcing 
their  way  in  ;  the  children  are  wailing  ;  there  is  a  noise  of 
crashing  and  banging  in  the  air.  The  patients  hear  scream- 
ing, "  whizzing,"  "  chatting  in  the  ear,"  "  frightful  talking," 
"  wholly  peculiar  matters,"  improper  things  ;  "  coarse  and 
refined  things  "  are  said  to  them  ;  it  is  a  "  secret  language  "  ; 
there  are  voices  from  heaven,  beneath,  voices  with  electric 
wires ;  sometimes  the  whole  body  speaks.  The  voices 
torment  them  all  day  long,  reproach  them  that  they  have 
lived  an  immoral  life,  that  they  have  committed  a  moral 
offence  on  themselves,  that  they  are  wanted  by  the  police. 
"  That  is  the  wickedest  man  of  all  "  they  say,  "  a  bastard  "  ;  he 
should  have  a  sound  thrashing,  his  ears  should  be  cut  off;  he 
should  be  executed,  slaughtered,  he  can  make  poison  ;  she 
has  a  child.  On  the  other  hand  it  is  said  to  the  patient  that 
he  is  to  get  a  uniform,  is  to  become  a  policeman,  is  to  marry. 
The  voices  question  him,  give  him  thoughts.  His  thoughts 
become  loud,  so  that  others  know  thenr,  and  he  can  com- 
municate with  the  whole  world  by  telephone  ;  it  is  said  to 
him  that  he  cannot  think.     A  female  patient  stated  that  she 


no     .  DEMENTIA  PRECOX 

often  felt  as  if  she  got  something  placed  quite  softly  in  her 
mind  when  she  was  thinking  of  nothing.  Strange  people, 
physicians,  speak  in  the  patient  and  he  must  speak  after 
them,  "  confirmations  to  be  spoken  out  in  a  low  tone  "  ;  his 
mother  forbids  him  to  eat;  a  voice  calls  upon  him  to 
slaughter  his  wife ;  a  female  patient  was  directed  to  take  off 
her  clothes. 

Food  has  a  peculiar  taste,  of  petroleum,  it  contains 
"shoenail  juice  and  potash";  it  smells  "of  poison,"  of 
sulphur ;  the  patient  is  conscious  of  oil  in  his  mouth,  of  the 
smell  of  powder,  he  is  being  chloroformed.  Something 
comes  against  his  face,  he  feels  that  he  is  being  pricked  all 
over,  that  his  neck  is  being  cut  off,  that  sand  is  being  spirted 
into  his  ears,  that  he  is  being  electrified ;  a  female  patient  got 
prickings  in  her  heart  when  anyone  died.  A  few  patients 
feel  sensations  in  their  body;  others  have  the  feeling  "that 
gentlemen  do  wicked  things  to  them,"  "so  tickling  things, 
which  are  not  pretty."  Often  such  sensations  are  interpreted 
in  an  extraordinary  way ;  a  female  patient  noticed  that  the 
physician  went  backwards  and  forwards  in  her  body  ;  a  male 
patient  felt  that  a  man  was  fastened  to  him. 

An  excellent  idqa  of  the  early  development  of  the  malady 
is  'afforded  by  the  following  extracts  from  the  description 
written  by  the  patient  herself,  a  musician,  who  fell  ill  very 
acutely  and  quickly  became  weakminded.  She  wrote  it  five 
weeks  after  the  beginning  of  the  illness  on  her  own 
initiative : — 

"In  the  following  night  I  was  electrified.  I  conclude  that  from  the  fact 
that  the  following  morning  I  felt  quite  peculiar  pains  and  twitchings,  and 
it  was  called  out  to  me  a  few  days  before  by  an  electrical  machine,  which 
had  inspired  me  with  all  possible  moods  and  thoughts,  and  by  means  of 
which  each  thought  is  understood;  'We  have  electrified  you'  ...  As 
a  great  criminal  was  conjectured  in  my  person  or  even  an  anarchist  (I),  I 
was  several  times  examined  electrically  on  my  conscience  with  the 
greatest  pains.  .Since  that  day  I  have  had  terrible  stories  of  murder  and 
theft  in  my  head,  which,  as  I  know  that  the  machine  is  still  always 
working  on  me,  can  absolutely  not  be  controlled.  .  .  .  Had  I  foreseen 
that  I  would  be  tormented  so  long,  I  should  have  noted  down  this  quite 
remarkable  torture  already  from  the  first  day  onwards  ;  now  un- 
fortunately I  can  still  remember  only  a  little.  I  make  notes  of  all  this 
for  myself  because  I  am  now  fearfully  unh.ippy.  I  feel  that  by  the  machine 
I  am  mentally  always  more  irritated,  and  have  already  often  asked  that 
the  current  should  be  stopped  and  my  natural  thinking  be  given  back  to 
me,  as  otherwise  within  measurable  time  a  catastrophe  could  easily 
occur.  Moreover,  it  appeared  to  me  as  if  papa  and  mama  were  also 
electrified  in  the  first  days,  as  I  very  distinctly  recognised  by  the  move- 
ments and  by  the  expression  of  the  face  of  my  parents  at  my  often 
dreadful  thoughts.  ...  I  must  here  mention  another  point  which  let  me 
understand  quite  well  that  the  machine  was  still  working.  This  is  that 
horrible  smells  from  time  to  time,  I  don't  know  how,  are  transmitted  to 


CLINICAL  FORMS  in 

me.  When  the  physician  examined  me  such  plague  smells  also  streamed 
out,  that  the  doctor  went  backwards  terrified.  .  .  .  One  evening  it  was 
called  out  to  me  by  the  machine  :  '  We  conjecture  in  you  the  murderer 
of  the  Empress  of  Austria  (!!!)'...  It  was  suggested  to  me  by 
electrical  means,  that  I  wished  to  murder  L.  ;  as  I  was  for  some  time 
speechless  about  it,  it  was  called  out  to  me  by  the  niachine  :  "You  have 
brought  great  shame  on  yourself  ...  As  on  this  I  had  to  endure 
frightful  pains — the  electric  current  went  as  already  before  through  my 
whole  body — it  was  called  out  to  me :  '  You  will  now  be  lynched  (I  !) '  .  .  . 
In  particular  the  last  word  (anarchist)  was  for  several  minutes  formally 
wound  round  my  head.  .  .  .  How  my  thoughts  are  all  so  exactly  under- 
stood and  whole  sentences  are  thrown  back  to  me  by  the  machine — this 
is  fact,  that  I  know  definitely  that  these  for  the  greatest  part  are  not 
my  own  thoughts — is  a  great  riddle  to  me.  This  must  be  a  very 
complicated  machine,  which  has  put  me  myself  in  any  emotional  mood 
whatever,  as  earnest,  cheerful,  laughing,  crying,  furious,  humorous — at 
different  limes  it  was  also  adjusted  to  grim  humour,  that  I  understood 
very  well — amiable,  morose,  energetic,  absent-minded  (very  frequently 
employed),  attentive,  dwelling  of  thoughts  on  one  point  to  unconscious- 
ness, yes,  even  to  madness — I  remember  one  evening  when  I  actually  did 
not  know  what  I  was  thinking — melancholy,  confused  and  so  on.  The 
very  remarkable  machine  is  also  able  to  give  me  sleep  suddenly,  to  keep 
away  sleep,  to  develop  dreams  in  me,  to  wake  me  up  at  any  time,  to  lead 
me  to  any  thoughts  whatever  as  also  to  a  definite  point  by  greater  tension 
of  the  electric  current  (or  however  this  is  managed)  further  to  lead 
off  the  thoughts,  indeed  even  to  suggest  any  movement  whatever  to  me. 
My  mind  is  excited  to  such  an  extent  and  the  most  incredible  thoughts 
come  to  me  chiefly  on  awaking  early  in  the  morning.  ...  I  try  to  control 
them  with  the  utmost  energy  ;  but  with  the  best  will  it  does  not  suceeed, 
so  long  as  the  machine  is  active  and  I  must  always  remember  it  as, 
besides,  my  thoughts  are  directly  drawn  out.  Also  in  reading,  it  may 
be  anything  whatever,  I  cannot  give  sufficient  attention  at  all  to  the 
contents  of  the  book  and  a  side-thought  comes  to  me  almost  at  each 
word.  ...  I  should  like  to  take  hold  of  another  point ;  that  is  an 
exaggerated  laughing  which  has  often  already  moved  me  quite 
peculiarly,  though  not  tormented  me,  and  which  I  could  hardly  control  at 
all.  Thi^  laughing,  which  is  by  no  means  painful,  was  transmitted  to  me 
just  when  I  had  thought  something  especially  stupid.  When  one  reads 
all  this  it  seems  to  be  the  greatest  nonsense,  that  ever  was  written  down  ; 
I  can,  however,  make  known  nothing  further  than  that  I  have  actually 
experienced  all  this  but  unfortunately  have  not  understood  it.  Probably 
only  he  will  understand  this  who  by  means  of  such  a  machine  has  been 
already  tormented  just  as  I  have  been  ;  probably  only  an  expert  will  be 
able  to  give  further  information  about  it." 

Perception,  orientation  and  the  working  up  of  external 
impressions  are  frequently  disordered.  The  patients  often 
mistake  persons  and  surroundings,  they  are  perplexed  and 
bewildered,  and  do  not  understand  their  position  and  what  is 
happening  around  them.  They  complain  that  they  are  no 
longer  as  they  were,  that  their  mind  is  failing,  their  thoughts 
are  all  confused,  that  they  cannot  collect  their  thoughts  any 
more  ;  their  memory  also  is  failing.  In  fact,  they  sometimes 
make  the  impression  of  stupidity  and  silliness,  are  confused 
and  easily  distracted ;  '  my  mind   and  sense  go  lost  diiring 


112  DEMENTIA  PR.«:COX 

conversation,'  said  a  female  patient.  Sometimes  to  the 
simplest  questions  nonsenical  answers  quite  away  from  the 
subject  are  given,  while  at  other  times  the  patients  do 
arithmetical  calculations  quickly  and  correctly  or  display  a 
fair  amount  of  school  knowledge. 

Delusions. — A  great  number  of  delusions  now  invariably 
develop,  some  of  which  are  most  amazing.  The  anxious 
confusion  of  the  patients  is  expressed  in  the  idea  that  every- 
thing is  falsified,  that  false  statements  are  made,  that 
there  is  war  in  the  whole  world,  that  the  world  is  being 
ruined,  that  they  are  "  in  an  enchanted  house."  "  It  is  a 
mystery,"  said  a  patient ;  the  greatest  events  happen,  the 
greatest  secret,  the  greatest  wonder  of  the  world,  that  devils 
come  into  heaven.  The  house  is  on  fire,  is  full  of  dead 
bodies  ;  the  provincial  court  was  taken  by  storm,  the  clergy- 
man was  stabbed  ;  the  French  are  coming ;  the  physician  is 
the  examining  magistrate,  the  Kaiser  ;  every  event  has  a  weird 
significance. 

Ideas  of  Sin. — Very  frequently  there  are  also  ideas  of  sin 
especially  in  the  beginning.  The  patient  has  misgivings 
about  his  past  life,  reproaches  himself.  He  is  a  wicked 
fellow,  has  made  mistakes,  has  told  lies  and  committed  theft, 
has  deceived  his  wife,  has  killed  his  children,  has  said  some- 
thing about  the  Kaiser,  has  destroyed  religion,  has  thought 
"  Godswine,"  is  to  blame  for  the  war,  for  the  death  of  a  noble- 
man, is  bringing  misfortune  on  his  family  ;  everyone  has  died 
on  his  account.  He  is  the  last  Judas,  is  rejected,  is  damned 
for  time  and  eternity,  is  the  anti-Christ,  cannot  be  saved,  is  to 
vow  allegiance  to  Satan  ;  his  children  are  in  hell.  He  is 
looked  on  as  a  great  criminal,  accused  of  theft,  of  indecent 
assault ;  he  must  die  for  the  sins  of  the  world. 

Ideas  of  Persecution. — Not  less  various  are  the  ideas  of 
persecution  that  are  developed.  Allusions  are  made  to  the 
patients;  they  are  watched,  stared  at,  spied  on,  laughed  at. 
They  are  influenced  by  sympathy,  bewitched,  stunned,  chloro- 
formed, hunted  like  a  wild  animal  in  flight.  Suspicious 
personages  meet  them  in  the  street ;  there  are  people  in  the 
cellar  ;  the  slater  will  kill  them  ;  the  policemen  are  coming 
to  drag  them  to  court.  A  raven  appears  at  the  window, 
which  will  devour  their  flesh  ;  there  are  serpents  in  their  bed  ; 
the  black  cat  is  coming  ;  hellish  spirits  are  threatening.  The 
physicians  give  them  poisonous  pills,  sprinkle  poison  in  their 
ears  ;  the  air  is  also  poisoned  ;  the  breakfast  is  made  dirty 
with  urine ;  there  is  human  flesh  in  the  food.  The  patient 
is  murdered,  executed,  burned,  cut  to  pieces,  sawn  asunder, 
dissected  alive,  trampled  by  a  horse.     His  children  are  ill  ; 


CLINICAL   FORMS  '  113 

his  wife  is  in  prison  ;  his  daughter  has  been  killed ;  his 
brother  is  dead  ;  his  little  boy  has  fallen  out  at  the  window ; 
all  Jews  are  being  beheaded  ;  a  mother  who  thought  her 
children  were  in  danger,  prepared  to  drown  them.  At  night 
they  are  ill-treated  ;  their  flesh  is  tampered  with,  their  breath 
is  twisted  off,  their  neck  is  broken  by  pressure,  their  strength 
is  drawn  out  of  them,  their  blood  is  driven  off,  the  nape  of 
their  neck  is  broken,  their  skull  is  being  proved ;  6ne  can 
"tear  him  with  words  from  below  upwards"  ;  with  words  his 
"legs  can  be  shaken  off."  His  brain  is  injured;  in  his  head 
everything  is  taken  part  in,  thoughts  are  "  made  incarnate  "  ; 
there  is  another  spirit  in  his  body.  His  nature  is  excited,  his 
semen  is  driven  off,  an  assault  is  made ;  the  nurse  makes 
sexual  advances.  As  has  been  mentioned  formerly,  the  per- 
secutions are  frequently  connected  with  the  nearest  relatives. 
His  family  will  bring  the  patient  to  the  gallows ;  his  father 
will  kill  him  ;  his  mother  is  a  witch  ;  a  female  patient  asserted 
that  she  had  been  sexually  ill-used  by  her  father.  The  wife 
is  contaminated  by  others  and  will  poison  the  patient. 

The  idea  of  the  change  which  has  taken  place  in  the 
patient,  often  takes  very  singular  forms.  The  patient  feels 
himself  weak,  gloomy,  not  right  in  his  head,  "  not  as  it  ought 
to  be."  His  head  is  "  a  rubber  tube  filled  with  blood  "  ;  every- 
thing is  rebellious  in  him.  His  brain  will  burst,  is  heavy, 
has  broken  through ;  his  understanding  is  destroyed  by 
onanism  ;  the  patient  cannot  think  alone,  so  cannot  live 
outside.  He  had  eaten  the  disease  with  a  sausage,  said  a 
patient ;  another  said  that  he  was  ill  because  of  a  disappoint- 
ment in  England  and  in  Kaiserslautern.  His  face  is  a  death- 
mask,  his  heart  is  dried  up,  hardened,  swollen  ;  his  bones 
rattle ;  loops  of  his  intestine  come  out  at  his  ear  ;  his  blood- 
vessels are  burst ;  the  connection  between  intestine  and 
stomach  is  broken  off;  everytliing  is  torn  off  and  drawn 
together.  The  patient  has  no  longer  a  stomach  or  an 
intestine  or  a  motion  ;  he  has  little  children  in  his  neck, 
serpents  and  snails  in  brain  and  body,  a  glazier's  diamond,  a 
church  tower  in  his  breast,  a  frog  in  his  stomach.  He  will 
not  get  better,  he  will  not  be  alive  to-morrow,  is  not  a  human 
being  any  more,  is  a  guinea-pig,  the  northern  lights,  is  dead, 
no  longer  in  the  world,  is  in  another  world  ;  "  I  am  as  if 
dead-born,"  said  a  female  patient.  A  patient  said  that  he 
must  make  the  Talmud,  his  wife  the  Acropolis  of  Athens  and 
then  marry  a  grand  gentleman,  while  he  was  being  murdered. 
Perhaps  such  senseless  utterances  are  connected  with  hallucina- 
tions ;  Bleuler  suggests  obscure  associations  caused  by  remote 
similarities  of  ideas  or  sounds  perhaps  also  indirect  associations. 

H 


114  DEMENTIA  PRi*:COX 

Exalted  Ideas. — In  a  number  of  cases  exalted  ideas  are 
present  also,  mostly  for  the  first  time  in  the  more  advanced 
periods.  The  patient  will  be  rich,  will  have  good  things  to 
eat,  get  a  situation  on  the  railway  of  the  Grand  Duke,  has  an 
excellent  memory,  possesses  means  to  make  people  omni- 
scient, has  the  "  imperial  attack,"  must  go  to  the  Kaiser.  An 
inheritance  of  a  million  is  being  kept  back  from  him  ;  his 
mother  is  not  his  own  mother,  his  father  is  a  Count,  Prince  of 
Leiningen,  the  Grand  Duke,  the  Emperor  Frederick  ;  he 
himself  is  a  millionaire.  Prince  of  Hesse,  possesses  a  third 
part  of  the  world  ;  "  Everything  belongs  to  me,  but  there  are 
also  shareholders,"  declared  a  patient.  The  patient  is  divinely 
gifted,  is  the  vicar  of  Christ,  the  son  of  almighty  God,  feels 
the  spirit  of  the  Saviour,  is  inspired,  fights  for  the  faith,  has 
the  Bible  and  the  world  in  his  head,  lives  eternally ;  the 
spirit  goes  forth  from  him  ;  a  patient  declared  he  was  the 
bride  of  the  Holy  Ghost.  Women  are  "the  bride  of  a 
gentleman  in  a  white  suit,"  hope  "to  get  a  husband, 
gentlemanly  and  aristocratic";  they  are  countesses,  angels, 
"  mother  of  the  world,"  the  bride  of  Christ,  their  sons  are 
princes  ;  a  female  patient  said  she  was  the  Mother  of  God, 
but  had  also  earned  it. 

Mood  is  at  first  anxious  and  depressed.  The  patients 
mourn,  they  howl,  they  break  out  into  convulsions  of  weeping, 
even  though  they  often  seem  singularly  indifferent  in  com- 
parison with  the  delusions  to  which  they  give  expression. 
Very  frequently  ideas  of  suicide  come  to  the  surface ;  the 
patients  beg  that  something  should  be  put  into  their  coffee,  that 
they  should  be  killed  because  they  cannot  live  any  longer; 
that  they  should  be  beheaded  as  they  will  not  get  really  well 
again.  Many  patients  also  make  attempts  at  suicide,  some- 
times impulsively  with  great  energy,  sometimes  more  as  in 
play.  Several  patients  jumped  out  at  the  window  ;  a  patient 
threw  himself  before  a  train  ;  a  female  patient  stabbed  her 
breast  with  a  knife  A  man  lay  down  in  front  of  a  beer- 
wagon  in  order  to  let  himself  be  run  over;  another  beat  his 
head  against  the  wall  ;  a  female  patient  "tried  how  drowning 
feels."  Not  at  all  infrequently  exalted  moods  are  interpolated 
in  the  periods  of  anguish,  giggling,  grinning,  and  laughing, 
especially  in  the  further  course  of  the  malady;  al.so  states  of 
irritated  excitement,  outbursts  of  obscene  abuse,  and  sudden 
dangerous  assaults  on  the  surroundings  often  occur.  A  few 
patients  display  in  the  beginning  of  the  disease  an  ex- 
aggerated piety  ;  they  kneel,  they  pray,  they  read  pious  books 
continuously,  they  wish  to  go  into  a  cloi.ster  ;  a  female  patient 
procured  the  robe  of   a   penitent;    another   reproached    the 


CLINICAL   KORMS  115 

clergyman  in  church  that  he  did  not  preach  rightly.  Sexual 
excitement  is  expressed  by  undressing,  taking  down  their 
hair,  improper  talk,  violent  masturbation,  which  sometimes  is 
ascribed  to  constraint  ;  a  female  patient  lay  down  in  a 
missionary's  bed  ;  a  male  patient  urinated  on  his  sister-in-law. 

The  Activities  and  Behaviour  of  the  patients  have  in 
part  a  certain  connection  with  their  hallucinations  and 
delusions.  They  listen  at  the  window,  speak  secretly  against 
the  wall,  exert  themselves  to  ward  off  invisible  people ;  a 
patient  begged  to  be  allowed  to  sleep  in  the  cellar,  that  he 
might  not  hear  the  voices  ;  another  was  afraid  of  the  alarum- 
clock.  Many  preach,  wish  to  confess  their  sins,  ask  the 
public  prosecutor  for  protection.  A  female  patient  hid 
herself  for  several  days  and  nights  in  the  forest  for  fright. 
The  aversion  to  relatives  leads  not  infrequently  to  hostile 
assaults.  A  patient  threatened  his  mother  with  a  knife ; 
another  was  going  to  kill  his  father  with  his  scythe. 

Very  frequently,  however,  a  motive  for  the  conduct  of  the 
patients  cannot  be  found  at  all ;  we  have  rather  to  do  with 
impulsive  actions,  such  as  are  so  frequent  in  dementia  prsecox  ; 
for  ought  we  know  vague  delusions  may  often  play  a  part. 
The  patients  throw  things  on  the  floor,  tear  the  clothes  off 
their  body,  seize  hold  of  the  physician  by  his  face,  steal  things 
from  their  neighbours;  bite  their  handkerchiefs ;  a  patient 
who  was  given  an  injection  immediately  bit  the  part  of  the 
skin  away.  Another  set  the  mill  going  by  night,  and  then 
set  fire  to  a  hay  stack,  in  doing  which  he  was  severely  hurt. 
Many  patients  devour  bees-wax,  dirt,  drink  the  bath  water. 
The  assaults  on  the  surroundings  also  may  be  wholly 
impulsive  ;  a  patient  felt  himself  urged  without  any  compre- 
hensible motive  to  kill  his  sister,  and  stabbed  her  without 
more  ado  in  the  arm. 

But  further  we  meet  in  the  patients  here  also  all  the 
peculiar  volitional  disorders  which  were  discussed  before. 
They  often  show  waxy  flexibility,  often  also  echo-phenomena  ; 
they  let  themselves  be  pricked  without  offering  any  resist- 
ance ;  they  assume  singular  attitudes  "  on  command,"  make 
faces,  blink,  utter  inarticulate  cries,  shake  their  heads,  make 
senseless  gestures,  pull  out  the  hair  on  their  genitals,  lie  about 
in  corners,  salivate  into  their  handkerchiefs,  behave  in  a  silly 
way,  "  like  a  flapper."  They  speak  in  a  whisper,  affectedly, 
mincingly,  in  a  singing  tone,  using  many  foreign  words,  a 
foreign  language;  they  address  the  physician  by  his  first 
name,  carry  on  confused,  drivelling  conversations,  verbigerate, 
give  utterance  to  silly  plays  on  words  and  senseless  doggerel, 
suddenly  break  out   into   bleating  laughter.     Negativism  is 


ii6  DEMENTIA  PRyECOX 

also  frequent.  The  patients  become  unapproachable,  give 
either  no  answer  or  an  evasive  one,  "  because  they  do  not 
need  to  say  it,"  do  not  shake  hands,  "  because  they  have  no 
time,"  hold  their  hand  before  their  mouth,  do  not  eat  because 
they  think  they  must  not,  or  "  because  they  live  on  the  word 
of  God,"  but  they  take  food  secretly  or  appropriate  their 
neighbours'  food.  They  force  their  way  out,  they  resist,  they 
do  not  let  themselves  be  undressed,  or  they  keep  no  clothes  on, 
they  lie  the  wrong  way  in  bed,  disown  their  name,  do  not  trouble 
any  more  about  their  surroundings,  do  not  occupy  themselves, 
remain  lying  in  bed  in  a  state  of  indifference.  Occasionally 
there  is' developed  a  pronounced  stuporous  behaviour;  ten 
years  after  the  appearance  of  severe  morbid  phenomena  a 
patient  sank  for  the  first  time  into  stupor  of  long  duration. 

The  Course  of  the  disease,  which  generally  is  progressive, 
was  in  14  per  cent,  of  the  cases  collected  here  interrupted  by 
improvement  more  or  less  complete,  which  lasted  as  a  rule 
one  to  five  years,but  occasionally  six  or  seven  or  even  nine  years, 
till  another  exacerbation  ushered  in  a  terminal  state.  This 
issue  was  in  20  per  cent,  of  the  cases  a  simple  weak-minded- 
ness, in  which  certainly  the  possibility  of  dementia  progressing 
still  further  must  be  reckoned  with.  Nearly  quite  as  frequent  was 
the  sinking  into  states  of  dementia,  sometimes  of  dull,  drivell- 
ing, negativistic  stamp,  seldomer  manneristic.  Seizures  were 
observed  in  27  per  cent,  of  the  cases.  The  form  here  dis- 
cussed corresponds,  therefore,  with  respect  to  the  final  issue 
to  about  the  average,  but  inclines  little  to  remissions  and  is 
accompanied  with  striking  frequency  by  seizures.  It 
includes  not  quite  13  per  cent,  of  all  the  cases.  Of  the 
patients  55  per  cent  were  men,  this  corresponding  just 
about  to  the  average ;  48  per  cent,  had  not  yet  passed  their 
twenty-fifth  year.  This  form  seems  accordingly  to  prefer 
somewhat  the  more  advanced  pv;riods  of  life,  a  circumstance 
to  which  we  shall  later  have  to  return. 

The  Agitated  Dementias. 
The  next  of  the  larger  groups  of  the  cases  includes  those 
in  which  states  of  excitement  more  severe  and  lasting  longer 
are  developed.  According  to  the  kind  of  clinical  symptoms 
which  appear,  but  specially  according  to  the  clinical  course, 
we  shall  here  be  able  to  separate  out  some  subordinate  groups. 
Further,  I  think  that  on  historical  grounds  I  should  keep  apart 
and  later  discuss  separately  that  form  of  dementia  praecox  in 
which  peculiar  states  of  excitement  are  associated  with 
stupor,  as  it  essentially  corresponds  to  the  picture  of 
catatonia  delineated  by  Kahlbaum. 


CLINICAL   FORMS  117. 

Circular  Dementia. 

The  first  subordinate  group,  which  on  account  of  the 
nature  of  its  course  we  may  perhaps  name  the  circular  form, 
at  first  shows  a  relationship  with  the  clinical  form  just  dis- 
cussed, in  as  far  as  it  also  begins  with  a  period  of  depression 
and  generally  is  accompanied  by  vivid  delusions.  The 
development  of  the  disease  takes  places  gradually  in  about 
56  per  cent,  of  the  cases  often  after  trifling  symptoms  have 
appeared  a  long  time  in  advance  ;  about  18  per  cent,  of  the 
cases  begin  acutely.  The  patienis  become  melancholy, 
anxious,  resistive,  morbidly  contemplative,  monosyllabic, 
stare  steadfastly  in  front  of  them,  and  express  thoughts  of 
death.  They  complain  of  sleeplessness,  nightmares,  oppression 
in  their  head,  sleepiness  ;  they  are  indifferent,  forgetful,  have 
an  aversion  from  work,  are  sometimes  restless,  irritable  and 
violent,  suffer  from  poverty  of  thought,  weak-mindedness,  have 
great  ideas,  but  no  energ)',  as  the  relatives  of  a  patient  stated. 
Not  infrequently  a  distinct  morbid  feeling  exists  at  the  same 
time.  The  patients  are  afraid  that  they  are  becoming 
insane  and  ask  for  help.  A  patient  desired  admission  to  the 
hospital  because  he  had  become  insane ;  such  improper 
thoughts  were  always  occurring  to  him.  Another  stated  that 
he  had  suffered  from  his  head  for  a  year  and  his  thoughts 
were  weakened.  A  third  said  that  he  had  been  slightly 
weak-minded  for  three  years  through  onanism. 

Hallucinations  are  very  commonly  present,  specially 
those  of  hearing.  The  patients  see  shadow-pictures,  ghosts, 
dead  people,  their  dead  parents,  one  of  their  children  without 
a  head,  two  devils ;  light  is  reflected  on  to  them  and  they  are 
dazzled.  They  hear  the  children  screaming,  a  band  of 
robbers  with  chains  rattling  in  the  wall;  the  bed  speaks,  the 
devil  chats  in  their  ear ;  a  man  who  has  been  hung  speaks. 
Their  name  is  called  out  ;  they  are  hoaxed,  mocked,  grossly 
abused,  tormented  with  the  telephone.  Unhappy  souls  are 
calling  ;  whole  poems  are  sounded  in  front  of  them  ;  there  are 
"  secret  gosslpings,"  voices  as  from  a  distance,  inward  voices 
of  thought,  suggestions,  inspirations,  the  thought-telephone. 
Thoughts  are  drawn  off  from  the  patient,  manufactured, 
suggested  ;  people  try  to  tempt  him  to  suicide  ;  he  must  kill 
his  child  ;  God  forbids  him  to  work  ;  he  carries  on  dialogues  in 
the  distance.  "  It  is  the  hopper  of  Niirnberg  ;  one  has  it  simply 
inside  one's  head  ;  the  machine  is  always  going  on,"  explained 
a  patient.  His  feet  are  besprinkled,  a  stream  is  carried  through 
his  head  ;  a  patient  had  the  feeling  as  if  his  eyes  were  being 
pressed  out ;  a  female  patient  complained  of  a  vulvar  smell. 


.ii8  DEMENTIA  PRECOX 

Delusions  are  predominantly  of  a  depressive  character. 
The  patient  feels  himself  constrained,  "  inwardly  repressed," 
he  is  "  utterly  confused  "  ;  "  my  mind  sometimes  goes  away," 
said  a  patient ;  another  said  that  he  was  dead  ;  a  female 
patient  said  that  she  had  lain  in  chloroform.  Their  heads  are 
hollow,  their  brains  are  rent,  burnt,  their  blood  and  their 
stomachs  are  in  bad  condition,  their  bowels  are  detached,  their 
voice  is  frozen,  their  throat  is  going  to  close.  Something  is 
being  done  to  their  ears;  the  patient  feels  himself  influenced 
especially  in  the  night ;  there  is  a  transference,  "something  false 
in  things";  "electricity  is  the  whole  business."  Signs  are  given  ; 
people  march  with  the  patient  keeping  step  with  him,  look  at 
him  suspiciously,  wish  to  thrash  him  ;  agents,  policemen, 
parsons  persecute  him.  He  is  bewitched,  laughed  at,  teased, 
sold,  and  sold  for  immoral  purposes,  dragged  about  the  whole 
house  by  night,  is  an  object  of  scorn  and  derision  ;  he  is 
sturtned,  beaten  on  his  head  with  a  hammer.  Filthy  and 
unchaste  deeds  are  committed ;  a  female  patient  thought 
that  she  was  always  having  children. 

The  husband  is  dead;  the  children  are"  executed ;  the 
physician  administers  poisonous  powders ;  the  patient  is  to  be 
killed,  burned,  he  will  have  a  leg  cut  off;  he  knows  "  what 
happens  underground."  He  is  to  blame  for  everything,  he  is 
the  devil  himself,-  has  stolen  money,  blasphemed  God,  dis- 
honoured his  children  and  mother,  is  possessed  of  the  devil,  is 
going  into  the  convict  prison  ;  he  is  being  tried  by  God,  will 
suffer,  will  eat  snails  for  three  months  and  die  of  hunger ;  will 
be  forged  to  chains:  his  feet  are  to  be  cut  off;  the  devil  is 
sitting  in  the  wall.  His  wife  wishes  to  poison  him,  takes  sides 
with  parsons  ;  his  father  will  strike  him  dead  ;  his  sister-in-law 
is  a  poisoner ;  father  and  brother  take  the  part  of  the  perse- 
cutors ;  he  must  therefore  provide  himself  with  weapons. 
Everything  is  changed ;  the  brother  is  exchanged ;  the 
husband  is  quite  different ;  a  female  patient  asserted  that  two 
different  men  came  by  turns  to  her.  The  physician  is  the 
Kaiser,  the  Crown  Prince  of  Sweden  ;  the  companions  in  the 
bedroom  are  not  patients  ;  the  hospital  is  the  house  of  the 
kingdom  of  God,  is  the  girl's  school.  Everything  is  on  fire ; 
the  home  is  burned  down  ;  famine  fever  will  break  out  ;  there 
is  war  ;  the  end  of  the  world  is  approaching.  At  the  same 
time  there  are  a  few  exalted  ideas.  The  patient  has  a  higher 
divine  calling,  is  William  I.,  General,  Admiral,  is  successor  to 
the  Prince  of  Lippe-Detmold.  Prince,  son  of  Count  Cotta  ;  he 
has  written  three  books,  is  getting  an  order  from  the  Prince 
Regent  of  Sweden,  has  castles  ;  everything  is  of  gold.  He  is 
Christ,  is  being  redeemed,  has  restored  dead  people  to  life. 


CLINICAL   FORMS  119 

Women  are  empresses,  redeemers  of  the  world,  are  going  to 
marry  the  physician ;  the  Kaiser  was  there  disguised  ;  a 
female  patient  thought  she  was  a  foundling  born  of  a 
man. 

As  already  appears  from  the  utterances  of  the  patients 
which  have  been  quoted,  their  consciousness  is  frequently 
somewhat  clouded  ;  they  often  have  an  obscure  idea, 
perverted  by  delusions,  of  the  persons  and  events  in  their 
surroundings  and  of  their  own  position.  Many  of  the 
patients,  however,  perceived  quite  well  and  even  were 
always  perfectly  clear  in  the  most  severe  states  of  excite- 
ment. The  .train  of  thought  is  confused  and  incoherent  ; 
in  conversation  there  appears  heightened  distractibility, 
interweaving  of  words  just  heard,  prolixity  along  with 
persistence  in  single,  ever-recurring  ideas.  A  few  of  the 
patients  wrote  sensible  letters,  while  others  furnished,  also 
in  writing,  wholly  disconnected  productions  ;  a  patient  sent 
us  for  a  long  time  innumerable  confused  postcards. 

Mood  is  subjected  to  very  severe  and  sudden  change.  The 
patients  are  sometimes  "inwardly  oppressed,"  "dejected," 
sometimes  immoderately  happy  ;  they  implore  pardon  one 
moment,  lament  their  profligacy,  beg  that  they  may  be 
saved,  and  in  the  next  moment  they  break  out  in  horse- 
laughter.  Just  as  suddenly  they  fall  into  the  most  senseless 
despair,  shriek,  cling  to  someone,  pray  passionately  "  in 
anguish  and  distress,"  cry'  and  scream  like  little  children  ; 
then  again  they  are  irritated,  grumble,  make  impertinent 
remarks,  threaten,  have  frightful  outbursts  of  rage,  scold 
without  measure  till  they  are  exhausted.  "  It  always  comes 
suddenly  in  ebullition,"  said  a  patient. 

Activities. — The  disorders  of  activity  are  invariably  ex- 
tremely manifold  and  striking.  The  actions  of  the  patients 
are  only  in  small  part  connected  with  recognizable,  though 
morbid  motives.  They  listen  for  the  voices,  try  to  drive 
away  invisible  forms,  pray  "  for  the  whole  of  mankind," 
prophesy,  preach,  make  confession,  drink  holy  water  on 
account  of  their  sins,  are  rude  towards  their  relatives,  by 
whom  they  believe  themselves  persecuted.  A  shoemaker 
asked  an  aristocratic  lady  in  marriage  assuming  that  she  was 
interested  in  him  ;  a  patient  with  jealous  ideas  summoned  his 
wife  before  the  sheriff-court. 

The  volitional  expressions  of  the  patients  are  really 
governed  by  an  innumerable  number  of  the  tnost  varied 
impulses  which  arise  in  irregular  sequence  from  the  peculiar 
excitement  which  is  developed  here.  Many  of  these  impulses 
lead  to  methodical,  although  senseless,  actions.     The  patients 


120  DEMENTIA    PR/ECOX 

run  off  aimlessly,  even  in  their  shirt,  wander  about  in  a  circle, 
adorn  themselves  with  gay  ribbons,  paint  the  walls,  scribble 
over  every  scrap  of  paper  or  stuff,  appear  bare-footed  in  the 
public-house,  climb  on  the  door,  throw  themselves  over  the 
head  of  the  bed  "  in  order  to  get  exercise,"  suddenly  lift  the 
physician  up  in  their  arms,  cut  their  hair  off,  undress,  make 
aimless  journeys,  put  their  hands  in  the  soup,  force  their  way 
with  the  greatest  effort  out  of  the  door,  wind  threads  round 
their  fingers  and  ears,  play  with  a  torn-off  button,  wear 
stockings  of  different  colours,  go  to  the  water-closet  innumer- 
able times.  Not  at  all  infrequently  they  become  really 
dangerous  to  their  surroundings.  They  try  to  light  a  fire 
under  the  bedstead,  they  throw  stones,  they  spit  in  people's 
faces,  throw  patients  out  of  their  beds  without  consideration. 
A  patient  smashed  the  sewing-machine  to  pieces,  another 
seized  his  wife  by  the  throat  and  threw  his  children  on  the 
floor ;  a  third  wanted  to  cut  his  children's  throats  ;  a  female 
patient  tried  to  kill  her  youngest  child.  Many  patients  ill- 
use  themselves,  and  for  days  and  weeks  almost  continuously 
they  make  attempts  at  suicide  before  the  eyes  of  the  people 
round  them,  try  to  throttle  themselves,  climb  up  the  window 
in  order  to  throw  themselves  down.  Feelings  of  shame  and 
disgust  go  into  the  background.  The  patients  strip  them- 
selves, hold  their  hands  on  their  genitals,  carry  on  improper 
conversations,  spray  dirt)-  bath  water  through  their  mouth 
and  nose,  wash  themselves  with  urine,  pass  urine  into  their 
slippers,  collect  their  faeces  in  their  pocket-handkerchiefs, 
smear  themselves  with  their  excreta  and  eat  them. 

But  by  far  the  most  characteristic  features  of  the  excite- 
ment of  our  patients  are  the  aimless,  impulsive  single  move- 
ments which  sometimes  overrun  the  whole  of  volition  and 
which  either  give  place  the  one  to  the  other  in  variegated 
change  or  are  repeated  with  slight  alterations  innumerable 
times.  The  patients  rub  their  hands  or  clap  them,  shake 
their  heads,  turn  somersaults,  throw  the  bed-clothes  about, 
tumble  about  on  the  floor,  frisk  about,  hop,  carry  out  turning, 
scrambling,  spreading  movements  with  the  arms,  twist  them- 
selves, tremble,  shake  themselves,  touch  or  tap  objects,  bore 
their  fingers  into  their  noses,  put  out  their  tongues,  make 
faces,  squint,  make  singular  gestures,  squirt,  splash  and  whirl 
in  water.  Excitement  makes  itself  conspicuous  also  in  the 
movements  of  expression.  They  bellow,  .screech,  scream, 
give  commands,  preach,  recite,  shout,  cry,  sometimes  with  a 
trumpet  voice,  sometimes  in  sweet  affected  tones  ;  they  sing, 
whistle,  pant,  snort,  clear  their  throats.  As  a  rule  they  are 
talkative,  mix  up  different  languages,  speak  with  nonsensical 


CLINICAL   FORMS  121 

intonation,  verbigerate,  let   themselves  go  in  silly  plays  on 
words  and  scraps  of  doggerel. 

With  these  are  associated  singular  positions,  theatrical 
attitudes.  The  patients  press  their  body  together  with  their 
hands,  lie  on  their  belly  or  in  cruciform  attitude  on  the  floor, 
twist  their  legs  round  each  other.  Indications  of  automatic 
obedience  and  negativism  are  also  frequently  encountered. 
The  patients  are  cataleptic,  imitate  what  is  done  in  front  of 
them,  scream  in  concert  when  others  scream  ;  a  patient  wrote 
words  that  were  called  out  to  him,  in  the  bath  water.  Others 
close  their  eyes,  press  their  lips  together,  throw  away  their 
food,  crumble  the  bread  that  is  offered  to  them,  and  then 
eat  secretly  or  snatch  food  from  others;  they  sleep  standing,* 
go  naked  to  bed  or  lie  the  wrong  way,  do  not  shake  hands, 
lie  down  in  other  people's  beds,  hide  themselves  away,  retain 
their  urine.  The  patients  are  often  to  some  extent  aware  of 
the  volitional  disorders  which  come  to  light  in  their  actions. 
"  I  can't  work  as  I  should  like,"  said  a  patient.  "  The  will  is 
there,  but  I  can't  get  it  out,"  said  another ;  a  third  declared 
"  Others  work  outside  with  my  mind."  The  patients'  explana- 
tion of  the  nonsensical  actions  is  that  they  were  under  com- 
pulsion, that  there  was  constraint  in  them. 

The  severity  of  the  states  of  excitement  here  described  is 
subject  to  great  fluctuations.  It  can  rise  from  the  slightest 
restlessness  even  to  unheard-of  violence  endangering  life. 
There  are  patients  who  for  weeks  and  sometimes  even  for 
months  are  almost  continuously  in  a  state  of  the  most  sense- 
less excitement.  Meantime  as  suddenly  as  the  excitement 
appeared,  just  as  abruptly  it  may  again  disappear ;  it  is 
exactly  the  alternation  between  complete  quiet  and  stormy 
excitement,  which  often  occurs  in  the  most  surprising  way  and 
isfrequently  repeated,  which  is  specially  peculiar  to  the  disease. 
The  duration  of  these  states  is  also  very  variable.  Sometimes 
there  are  only  short  interpolations  -lasting  a  few  days  or 
weeks  ;  in  other  cases  a  constant  restlessness  continues  for 
months  and  even  for  years,  which  frequently  rises  to  more 
severe  states  of  excitement  even  in  fairly  quiet  interludes. 

The  course  of  the  disease,  which  in  general  progresses 
from  depression  through  excitement  to  a  terminal  state,  was 
interrupted  in  53  per  cent,  of  the  cases  by  periods  of  con- 
siderable improvement,  in  nearly  14  per  cent,  even  several 
times.  These  remissions  lasted  in  the  half  of  the  patients 
concerned  up  to  three  years,  in  the  other  half  up  to  ten 
years.  In  70  per  cent,  of  the  cases  the  improvement  was 
interpolated  after  the  preliminary  depression  ;  several  times 
periods    of  depression    preceded,   separated   by    more   lucid 


122  DEMENTIA    PR.ECOX 

intervals.  After  the  improvement  the  disease  then  generally 
continued  with  a  state  of  excitement  leading  to  dementia  ; 
less  frequently  a  state  of  depression  was  again  interpolated 
and  the  first  excitement  followed.  In  those  cases  which 
only  improved  after  a  preliminary  depression  with  excite- 
ment following,  the  relapse  usually  began  again  with  a  state 
of  excitement  leading  now  to  dementia  ;  less  frequently  a 
state  of  depression  was  once  more  interpolated,  or  psychic 
weakness  was  developed  gradually  after  the  expiration  of 
the  more  lucid  interval  without  more  striking  morbid  pheno- 
mena. The  duration  of  the  attacks  till  the  terminal  state 
was  reached,  was  sometimes  only  a  few  weeks  or  months,  more 
rarely  one  to  two  years.  The  issue  was  in  almost  a  quarter 
of  the  cases  simple  weak-mindedness  ;  the  same  number  of 
patients  sank  into  complete  dulness,  while  in  the  remaining 
cases  sometimes  more  a  talkative  incoherence,  sometimes 
more  an  odd  manneristic  behaviour,  here  and  there  also 
negativism,  accompanied  the  psychic  decline.  A  patient 
died  in  the  course  of  a  very  severe  and  lasting  state  of 
excitement  without  organic  disease.  Seizures  occurred  in 
one-fifth  of  the  patients.  According  to  the  course  and  issue 
the  form  here  described  may  therefore  be  termed  a  com- 
paratively favourable  form  of  dementia  praicox.  It  includes 
something  over  9  per  cent,  of  the  cases  made  use  of  in  this 
enquiry.  The  share  of  the  male  sex  with  53  per  cent,  corre- 
sponded nearly  to  the  average  ;  as  61  per  cent,  of  our  patients 
had  not  yet  passed  their  twenty-fifth  year,  it  seems  in  com- 
parison to  the  general  average  number  of  57  per  cent,  that 
in  these  forms  which  run  a  more  favourable  course,  the 
younger  patients  are  somewhat  more  largely  represented. 

Agitated  Dementia. 

As  second  subordinate  group,  an  agitated  form,  we  bring 
together  those  cases  in  which  the  disease  begins  with  a 
state  of  excitement  and  then  directly  or  after  more  or  less 
numerous  remissions  and  relapses,  passes  into  the  terminal 
state.  The  development  of  the  di.sease  is  accomplished  in 
45  per  cent,  of  the  cases  suddenly,  while  in  about  a  third  of 
the  cases  for  a  considerable  time  prodromal  morbid  pheno- 
mena have  been  noticeable.  As  a  rule  the  patients  become 
e.xcited,  irritable,  insubordinate,  violent ;  they  run  away,  carry 
on  nonsensical,  disconnected  conversations ;  sometimes  a 
conditifin  of  great  confusion  appears  quite  abruptly. 

Hallucinations,  especially  of  hearing,  play  a  considerable 
part  here  also.     The  patients  see  fiery  balls,  must  "  watch  the 


CLINICAL   FORMS  123 

light  day  and  night,"  must  watch  the  "dazzh'ng  h'ghts," 
Pictures  are  put  before  them  ;  they  see  four  people  swinging 
who  have  been  hung  ;  they  see  mice,  ants,  the  hound  of  hell, 
a  white  star,  devils,  angels,  black  men,  people  with  knives, 
scythes  and  axes.  They  hear  cocks  crowing,  shooting,  birds 
chirping,  spirits  knocking,  bees  humming,,  murmurings, 
screaming,  scolding,  voices  from  the  cellar,  or  from  above 
downwards  ;  the  walls  speak,  ghosts  talk,  there  is  chatting 
going  on  in  their  body.  The  voices  say  "  filthy  things,"  "all 
conceivable  confused  stuff,  just  fancy  pictures  "  ;  they  speak 
about  what  the. patient  does,  "as  if  he  had  arranged  some- 
thing," they  reproach  him  for  eating  too  much,  they  comfort 
him.  They  say  :  "  That  man  must  be  beheaded,  hanged," 
*'  Swine,  wicked  wretch,  you  will  be  done  for";  his  wife  calls 
out, "  Beast  of  a  fellow  !  "  the  death  of  the  patient  is  discussed. 
Visual  and  auditory  hallucinations  are  often  connected.  A 
patient  saw  an  angel  who  announced  to  him,  "  Make  atone- 
ment, I  will  crown  thee  "  ;  it  was  said  to  a  female  patient  by 
a  child  whom  she  saw  lying  beside  her:  "  Wait,  till  I  get 
you  !  "  The  voices  proceed  sometimes  from  God,  sometimes 
from  the  devil,  from  spirits  and  ghosts,  from  the  mayor's 
daughter  ;  there  are  people  under  the  bath.  Machines  repieat 
what  the  patient  thinks,  his  thoughts  are  open  to  others  ;  they 
are  drawn  off,  and  strange  unfavourable  thoughts,  such  as 
come  from  the  devil,  are  suggested.  The  angel  Gabriel  com- 
mands ;  "  voice-interference "  takes  place.  The  patient  is 
stupefied  by  smelling-stuff ;  the  air,  the  food  is  stinking,  they 
contain  dirty  things  ;  the  water  is  salt.  People  spit  in  his 
face,  treat  him  with  electric  currents  ;  he  feels  the  shocks,  is 
strangled,  is  rocked  ;  at  night  a  lieutenant  pulls  him  by  the 
genitals  ;  he  is  cupped  every  evening  ;  he  can  get  no  air  ;  in 
his  bed  there  are  fleas  and  vermin  ;  "  they  make  a  man  tired." 
A  patient  had  a  feeling  as  if  everything  were  breaking  down, 
and  called  out :  "  I  am  falling." 

Perception  and  Understanding  of  the  Surroundings 
are  frequently  disordered.  Many  patients  are  as  if  lost  in  a 
dream,  are  perplexed,  say  that  everything  is  muddled,  every- 
thing turned  upside  down  ;  the  world  is  being  ruined  ;  there 
is  a  religious  war  ;  the  axis  of  the  world  is  tilted  over.  They 
mistake  people,  call  the  physician  their  father,  the  local 
member  of  the  School  Board  the  Duke  of  Orleans,  the 
Saviour  ;  they  call  a  fellow-patient  their  sister ;  they  are  in 
a  manufactory,  in  France,  in  a  nunnery,  in  church,  in  the 
*'  Schnallenhallenhaus."  At  the  same  time  they  are  as  a  rule 
poor  in  ideas,  distractible,  monotonous  in  their  utterances, 
they  weave  in  words  which  they  have  heard  without  under- 


124  DEMENTIA    PRECOX 

standing.  Through  this  the  condition  acquires  the  features 
of  acute  confusion,  especially  when  vivid  hallucinations  are 
present,  and  is  frequently  so  interpreted.  Other  patients, 
however,  always  remain  surprisingly  clear,  make  suitable 
remarks,  solve  problems  in  arithmetic  quickly  and  correctly. 

Delusions,  are  connected  at  first  with  the  feeling  of  the 
change  experienced.  The  patients  feel  themselves  "confused 
and  constrained,"  "  not  right  in  the  head,"  "  scattered  in  their 
mind,"  quite  bewildered,  "  so  confined  "  ;  they  have  *'  such 
childish  things  in  them,"  they  do  not  know  what  they  should 
say.  Everything  is  destroyed  in  their  head,  "evaporated," 
"  completely  done  for."  "  I  was  a  stupid  fellow  from  the 
beginning,"  declared  a  patient;  another  said,"  I  am  no  longer 
as  I  was,  had  no  more  thoughts,  did  not  know  where  I  was 
going;"  a  third  said,  "I  am  quite  stupid,  I  know  nothing 
more  ";  a  fourth,  "  I  am  becoming  half  mad,  I  can  no  longer 
understand  anything."  Other  hypochondriacal  ideas  are  also 
expressed.  The  patient  has  fever,  phthisis,  pains  in  his 
body  ;  he  cannot  breathe,  has  just  almost  died  ;  his  blood  is 
not  moving  ;  his  arms  are  cut  off,  are  sometimes  fatter,  some- 
times thinner;  his  limbs  are  changed,  his  body  burned,  his 
leg^  are  broken  ;  a  little  monster  is  sitting  on  his  chin,  a 
bludgeon  on  his  back  ;  there  is  wax  in  his  body,  cold  in  his 
brain  ;  a  patient  thought  that  the  one  half  of  him  was  male, 
the  other  female. 

Ideas  of  Sin,  of  Persecution,  and  of  Influence. — Ideas  of 
sin  play  a  small  part.  The  patient  has  done  everything  bad, 
is  a  Jacobin,  anarchist,  and  nihilist,  is  going  into  the  convict 
prison  ;  the  evil  one  is  fetching  him.  Neither  are  ideas  of 
persecution  much  in  evidence.  The  patient  leads  the  life  of 
a  martyr,  gets  hard,  mouldy  bread  and  the  smallest  pieces  of 
meat,  does  not  get  the  right  wages,  is  being  poisoned  with 
prussic  acid,  is  being  persecuted  by  the  magistrates,  by  a 
servant  girl,  is  regarded  as  a  spy,  is  chosen  by  his  family  as 
the  sacrificial  lamb  ;  at  night  his  bed  and  clothes  are  .soiled  ; 
people  are  going  to  take  his  money  from  him.  He  is  to  be 
murdered,  thrown  into  a  grave,  does  not  want  to  go  to  the 
scaffold.  A  misfortune  is  going  to  happen  ;  a  flash  of  lightning 
is  coming ;  his  parents  are  burned ;  his  sister  has  died  ;  his 
wife  has  hanged  herself  Not  infrequently  we  meet  ideas  of 
influence.  The  patient  feels  himself  magnetized,  under  a  ban, 
as  if  electrified,  influenced  by  God,  by  the  look  of  the  attendant ; 
he  has  a  machine  in  his  body ;  everything  that  he  does  is 
destiny  ;  he  mu.st  stay  in  bed  "on  command."  His  cough  is 
made  by  the  physicians  ;  people  attack  him  at  night,  torment 
him,  will  make  him  mad  ;  "  the  beastly  swine  were  at  me," 


CLINICAL   FORMS  125 

said  a  patient.  Female  patients  are  raped,  chloroformed,  and 
dishonoured  ;  a  female  patient  believed  that  she  had  become 
pregnant  by  a  shadow  and  that  abortion  had  been  committed. 
Exalted  ideas  are  the  most  frequent.  The  patient  feels 
himself  destined  to  great  things,  works  beside  royalty,  can 
put  anyone  into  prison,  speaks  many  languages,  is  to  be  a 
professor,  will  teach  at  a  university,  is  getting  an  inheritance 
from  the  Australian  Kaiser,  possesses  fifty  estates,  millions. 
He  is  Li-Hung-Chang,  Prince,  son  of  the  King  of  Wiirtem- 
berg.  Majesty,  Napoleon,  Kaiser  ;  a  patient  asked  on  admission 
if  the  European  Concert  had  been  informed.  The  patient 
receives  revelations  from  God,  is  going  to  write  a  book  about 
a  new  Christianity,  is  going  to  redeem  the  world,  has  wrestled 
with  the  devil,  was  in  heaven  ;  he  is  the  "  father  of  his  own 
mother,"  mediator  between  God  and  men,"  Lord  Holy  Ghost," 
is  waiting  for  redemption,  for  the  last  judgment.  He  can 
heal  the  sick  ;  he  will  do  away  with  menstruation  in  women  ; 
no  one  is  going  to  die  any  more.  Female  patients  become 
rich  women,  have  money  in  the  savings-bank  for  their 
children,  are  getting  a  Lord  Mayor  for  a  husband,  are  to 
marry  a  priest.  A  female  patient  declared  she  was  the  Queen 
of  Heaven,  and  wished  to  have  a  private  water-closet.  The 
following  extract  from  a  letter  may  give  an  idea  of  the  sense- 
lessness and  incoherence  of  the  delusions  : 

"  Let  it  be  your  business,  dear  T.,  that  you  in  the  new  year  have  the 
empty  room  put  full  of  continents  and  increase  your  fortune  and  your 
fame  to  the  infinite.  In  this  case  you  will  take  the  second  place  in  the 
world  and  will  have  a  happy  future.  Millions  of  continents  are  given  to 
your  care  and  providence  and  happy  in  your  theism.  That  you  till  now 
are  still  lethargic,  that  can  finally  be  redressed  and  we  shall  hope  the 
best  for  you.  Lethargy  is  devil's  work  and  needs  presumably  time  for 
removal.  But  how  to  remove  your  argie?  It's  that  that  causes  me 
trouble.  Drink  plenty  of  wine  and  beer  and  move  about  a  great  deal 
in  society,  then  it  will  pass.  You  will  not  finally  get  rid  of  your  creation- 
stain  at  all — A  merry  life  and  fortunate  future. 

With  hearty  partial  honour-sympathy  your  friend  and  brother 

H.H.  (Name  of  the  superintendent  of  the  institution). 

"  Holy  Ghost  and  third  person  in  the  Godhead. 

"  Nota  bene  :  obediently  to  serve  that  I  must  later  generate  a  son 
from  myself;  he  will  receive  the  title  'Son  of  God,'  and  will  be  generated 
as  from  the  holy  third  spirit  and  received  as  second  person  in  the  God- 
head. Otherwise  we  have  with  us  no  splendour  and  no  consideration. 
Upon  you,  dear  T.,  I  bestow  as  New  Year's  present  the  title  'glorious, 
sole  councillor  and  dear  almanac.'" 

Mood  is  in  general  exalted,  more  rarely  anxious,  but 
always  subject  to  extraordinarily  sudden  and  severe  fluctua- 
tion. Whimpering,  bewilderment,  wild  laughing,  frightful 
outbursts  of  abuse,  unrestrained  merriment  may  make  place 


126  DEMENTIA    PRECOX     ' 

for  each  other  without  intermission.  The  behaviour  of  the 
patients  towards  their  relatives  shows  complete  indifference. 
Sexual  excitement  is  expressed  in  masturbation,  indecent 
assaults,  jealous  ideas,  and  exposure  of  themselves  ;  a  female 
patient  hung  her  bloody  chemise  in  front  of  the  window.  A 
patient  was  very  much  irritated  by  his  father  who,  he  said, 
always  forced  him  to  masturbate ;  another  felt  himself 
constrained  to  cohabit  with  his  sister.  Now  and  then  homo- 
sexual tendencies  come  to  the  front. 

States  of  excitement  have  the  same  features  as  in  the 
group  last  described.  Only  within  narrow  bounds  does  the 
behaviour  of  the  patients  appear  to  some  extent  compre- 
hensible. Thus  there  might  be  a  connection  with  religious 
delusions  when  a  patient  rings  the  bells  by  night,  lights  the 
altar  candles,  begins  to  preach  in  church,  takes  objects  from 
the  altar,  wishes  to  open  graves,  burns  the  stigmata  on 
himself  with  his  cigar.  Ideas  of  persecution  lead  to  the 
patients  wishing  to  appeal  to  the  police,  to  provide  them- 
selves with  a  revolver,  to  make  a  visit  "  only  with  a  strong 
escort,"  to  cut  their  wife's  throat.  Patients  with  exalted 
ideas  make  purchases,  make  senseless  presents,  forge  plans 
for  getting  engaged,  write  letters  to  Grand  Duke  and  Kaiser, 
wish  to  go  to  Rome  to  liberate  the  Pope.  Those  with  ideas 
of  sin  kneel,  pray,  beg  for  forgiveness ;  a  female  patient  put 
on  her  Sunday  clothes  and  was  going  to  jump  out  at  the 
window  in  order  to  reach  God,  because  she  had  not  confessed 
everything.  Hallucinations  have  as  a  consequence  that  the 
patients  stop  up  their  ears  with  paper  and  bread,  and  try  to 
chase  away  spirits  ("  away  with  the  devil !  ")  ;  a  female  patient 
threw  the  goldfish  into  the  water-closet  because  they  carried 
on  blasphemous  conversation. 

But  on  the  whole  the  excitement  consists  of  impulsive 
actions  and  senseless  movements.  The  patients  run  aimlessly 
about,  play  tricks,  mix  up  their  bedclothes  altogether,  tear 
up  and  destroy  things,  throw  chairs  and  spittoons  about, 
smash  panes  of  glass,  fling  their  food  about  the  room,  throw 
their  watch  down  the  water-closet ;  they  march  out  naked, 
they  throw  things  at  the  burning  lamp.  Others  scratch  their 
faces,  dash  headlong  out  of  bed,  stick  the  handle  of  a  spoon 
into  their  anus,  pull  out  their  teeth,  try  to  strangle  themselves, 
beat  their  faces,  pull  at  their  genitals,  at  their  ears,  all  being 
done  impulsively,  suddenly,  with  great  violence  and  without 
recognizable  motive.  The  very  frequent  and  dangerous  attacks 
on  their  surroundings  also  bear  the  same  stamp.  The  patients 
without  any  consideration  throw  their  relatives  on  the  floor, 
knock  down  a  neighbour,  rush  at  an  unknown  person  with  a 


CLfklCAL   FORMS  127 

fork,  bite  the  arm  of  the  attendant ;  a  patient  took  hold  of  an 
attendant's  finger  so  firmly  with  his  teeth  that  he  could  only 
be  made  to  let  go  under  an  anaesthetic.  The  senselessness  of 
these  actions  is  made  clear  by  the  fact  that  the  patients  one 
moment  impetuously  embrace  a  person  and  next  moment 
perhaps  belabour  him  with  their  fists. 

But  besides  these  actions,  which  after  all  have  a  Certain 
relation  to  the  surroundings,  a  disorderly  series  of  completely 
aimless  movements  are  further  carried  out,  usually  with  a 
tendency  to  innumerable,  uniform  repetitions  and  to  rhyth- 
mical arrangement.  The  patients  run  round  at  a  gallop 
always  the  same  way,  run  round  the  house  till  they  are 
exhausted,  they  jump  up  and  down  with  great  leaps,  march 
in  the  garden  "  as  if  they  had  the  strictest  order  from  the 
colonel,"  cut  capers,  dance  about  singing,  carry  out  military 
movements,  "physical  drill,"  flourish  their  arms,  beat  time^ 
knock  and  drum  on  the  bedstead,  turn  round  about,  write 
figures  in  the  air.  They  let  themselves  fall  on  the  floor,, 
waltz  round  about  bellowing,  prance,  fall  over  and  roll  about, 
grind  their  teeth,  pull  hideous  faces,  spray  and  spit  about 
them.  In  its  most  simple  forms  this  restless  movement 
becomes  stretching,  shaking,  trembling,  choreic  jerking  of  the 
hands,  tripping  and  stamping,  balancing  and  rocking,  dis- 
torting of  the  arms  and  legs,  as  we  find  it  again  in  the 
terminal  states  as  a  residuum  of  the  severe  and  acute  volitional 
excitement.  In  the  domain  of  the  movements  of  expression 
the  excitement  makes  itself  conspicuous  in  singing  and  play- 
ing the  harmonica  for  hours,  in  shrill  screaming  and  screeching^ 
in  the  inarticulate  utterance  of  senseless  sounds,  in  cease- 
less flow  of  words,  reciting,  rhyming,  scolding,  panting, 
groaning,  hissing,  whistling,  sighing ;  some  patients  say 
everything  singing  ;  others  speak  in  gibberish  invented  by 
themselves. 

Besides  the  impulsive  discharges  th^  signs  of  the  other 
volitional  disorders  which  are  peculiar  to  dementia  praicox 
are  also  invariably  found  here.  The  movements,  actions  and 
attitudes  of  the  patients  are  frequently  manneristic,  some- 
times clumsy  and  awkward,  sometimes  affected  and  florid. 
The  patients  assume  odd  attitudes,  twist  themselves  together, 
balance  themselves,  hold  the  lobe  of  one  of  their  ears  tight 
for  months,  behave  in  a  theatrical  manner,  only  give  the 
finger-tips  in  shaking  hands,  bolt  their  food  without  chewing 
it,  dress  their  hair  in  an  extraordinary  way.  A  female 
patient  sewed  white  figures  on  to  her  jacket  ;  a  patient  knelt 
down  each  time  he  came  in  or  went  out.  Others  speak  in 
a  stilted   manner,   with    high-sounding   phrases  ;    a   patient 


128  DEMENTIA    PRECOX 

wrote  letters  in  dog-Latin.  Frequently  automatic  obedience 
is  present,  the  patients  imitate  and  follow  closely.  Negativ- 
istic  phenomena  also  meet  us  almost  everywhere.  The  very 
inaccessibility  of  the  patients  and  their  want  of  susceptibility 
to  influence  might  be  interpreted  in  this  sense.  They  do  not 
listen  to  what  is  said  to  them,  obey  no  injunctions,  do  not  let 
themselves  be  disturbed  in  any  way  in  their  senseless  on- 
goings, not  even  by  force,  do  not  show  the  slightest 
consideration  for  their  surroundings.  They  give  no  answers 
to  questions  or  else  nonsensical  or  unrelated  ones ;  they 
arbitrarily  apply  names  to  people  whom  they  recognize 
correctly.  They  crouch  under  the  bed-cover,  stick  their 
head  under  the  pillow,  endure  no  clothes,  do  not  remain  in 
bed,  do  not  change  their  shirt,  do  not  let  themselves  be 
undressed,  retain  their  urine  and  then  soil  the  bed,  eat  only 
when  unobserved  or  eal  the  food  of  other  people,  keep  their 
bread  for  hours  in  their  mouth.  A  patient  let  himself  be 
only  half  shaved,  then  ran  away  ;  a  female  patient  tied  on 
her  apron  the  wrong  way.         , 

Here  also  the  severity  of  the  excitement  may  be  of  very 
varying  degree,  from  slight  silly  restlessness  to  raving  mania 
of  the  most-  severe  type.  The  impulse  to  movement  may 
become  so  uncontrollable  and  so  regardless  that  it  seems 
scarcely  possible  to  procure  any  rest  even  for  a  short  time 
for  the  patients  and  their  surroundings.  Bruises  and  abrasions 
and  even  more  serious  injuries  can  in  certain  circumstances 
not  be  prevented  at  all.  At  the  same  time  the  sense  of  many 
of  the  patients  is  very  surprising ;  they  may  be  quite  clear 
about  their  situation  and  surroundings,  but  just  as  surprising 
is  then  the  abrupt  commencement  and  the  equally  sudden 
cessation  of  the  excitement  which  often  appears  in  the 
form  of  limited  attacks  of  shorter  or  longer  duration. 

Course. — The  states  here  described  may  pass  after  many 
fluctuations  directly  into  incurable  states  of  weakness.  In 
36  per  cent,  of  the  ca.ses,  however,  after  the  first  attack  there 
is  a  remission  of  all  morbid  phenomena,  which  in  10  per 
cent,  of  the  cases  may  even  be  repeated  once  or  indeed 
several  times  before  the  terminal  state  is  reached.  The 
duration  of  these  periods  of  improvement  fluctuates  from  a 
few  months  to  twelve  or  fourteen  years  ;  it  is  most  frequently 
about  three  years.  The  recurrence  of  the  disease  occurs 
usually  with  fresh  states  of  excitement,  somewhat  seldomer 
in  the  form  of  progressive  dementia,  now  and  then  also 
perhaps  with  a  state  of  depression  to  which  excitement  may 
again  follow,  terminating  in  dementia.  When  there  are 
repeated  remissions  of  the  disease  the  states  of  excitement 


CLINICAL   FORMS  129 

may  return  more  frequently.  In  one  case  I  observed  first 
four  states  of  excitement  separated  by  periods  of  improve- 
ment lasting  for  some  years,  of  which  two  terminated  in 
depression  ;  then  there  followed  after  a  clear  interval  of  fifteen 
years  a  state  of  confusion  which  led  to  a  final  state  of 
dementia,  which  I  followed  for  eight  years. 

A  simple  weak-mindedness  of  varying  degree  was  the 
issue  in  27  per  cent,  of  the  cases  of  the  form  here  described. 
Nearly  in  the  same  ratio  a  state  of  dementia  with  marked 
mannerisms  was  the  result,  somewhat  seldomer  a  psychic 
decline  with  predominating  incoherence  or  with  dull  indiffer- 
ence; one  patient  died  by  suicide.  Seizures  were  observed  in 
approximately  a  fifth  of  the  cases.  Evidently  we  may  regard 
this  form  also  of  dementia  pra^cox  as  relatively  favourable. 
It  includes  about  14  per  cent,  of  the  total  number  of  our  cases. 
The  male  sex  was  represented  by  60  per  cent.,  and  the  ages 
under  the  twenty-fifth  year  were  the  same  ;  in  both  directions, 
therefore,  the  numbers  are  somewhat  over  the  average.  It  is 
perhaps  not  without  interest  to  remark  that  the  form  described 
seemed  to  me  to  be  by  far  the  most  frequent  among  the 
numerous  cases  of  dementia  praecox  observed  among  the 
natives  of  Java. 

Periodic  Dementia. 

In  close  connection  with  the  cases  brought  together  in 
the  last  section  we  have  still  to  mention  a  small  group  which 
runs  a  pronounced  periodic  course  either  in  the  introductory 
stages  of  the  disease  or  during  its  whole  duration  ;  its  number 
amounts  to  not  quite  2  per  cent,  of  all  cases.  The  outbreak 
of  the  disease  occurred  in  two-thirds  of  my  cases  before  the 
twentieth  year,  sometimes  at  fourteen  years  of  age.  With 
shorter  or  longer  intervals,  often  very  few  weeks,  sometimes 
only  once  a  year,  confused  states  of  excitement  appear  which 
run  a  rapid  course.  In  the  female  sex  they  are  frequently 
connected  with  the  menstrual  periods  in  this  way,  that  the 
attack  begins  with  the  commencement  of  the  menses  or  even 
a  short  time  before,  and  then  lasts  about  one  or  two  weeks 
till  it  makes  way  for  a  clear  interval  lasting  usually  somewhat 
longer  ("  menstrual  insanity  ").  The  commencement  of  the 
excitement  is  as  a  rule  quite  sudden.  After  at  most  slight 
indications  of  the  commencing  attack,  causeless  laughter, 
blinking  of  the  eyes,  wandering  about,  have  preceded,  there 
is  developed  from  one  day  to  another,  often  in  the  middle  of 
the  night,  the  picture  of  maniacal  excitement.  Sometimes  it 
is  limited  to  heightened  irritability,  change  of  mood,  restless- 

I 


130 


DEMENTIA    PRECOX 


ness,  incessant  chatter  ;  but  gradually  the  excitement  becomes 
worse,  going  on  even  to  raving  mania  of  the  most  severe  type, 
often  with  delusions  and  hallucinations.  The  body  weight 
invariably  decreases  rapidly,  sometimes  as  much  as  five  to 
eight  pounds  in  twenty-four  hours  (Furstner).  Fig.  25  shows 
the  fluctuations  during  a  prolonged  series  of  attacks  up  to 
death.  The  excitement  often  lasts  only  a  few  days  or  weeks, 
more  rarely  it  continues  for  months  and  then  is  interrupted 
by  only  a  few  quiet  days.  Usually  the  intervals  are  some- 
what longer,  a  few  weeks  or  months.  In  course  of  time  the 
duration  of  the  attacks  may  be  extended. 

The  commencement  of  the  quiet  period  takes  place  usually 
just  as  quickly  as  that  of  excitement,  even  though  one  can 
generally  notice  already  towards  the  end  of  the  attack  a 
slight  decrease  of  confusion  and  restlessness.     The   patient 


A  _,    f^ h    ^^hjs    /Tj .     * 

A±57rn3tTEr47^T  . 

I^^JV  jr^JTlL^v^^'^UTlv 

4  ^^^       ^                  hXv 

1                      it      ^r 

X 

I 

i 

Fig.  25.     Fluctuations  of  body  weight  in  periodic  excitement. 

is  now  all  of  a  sudden  reasonable,  but  remarkably  quiet, 
indifferent,  dull,  and  has  not  as  a  rule  complete  insight  into 
the  morbid  nature  of  his  state  even  though  he  still  remembers 
well  many  details.  He  rather  tries  to  represent  the  excite- 
ment, which  he  has  gone  through,  as  something  quite  harm- 
less or  as  caused  by  the  surroundings,  the  restraint  in  the 
institution  and  that  sort  of  thing.  He  considers  himself 
already  on  the  first  day  of  the  commencing  state  of  quiet 
as  completely  recovered,  and  urgently  desires  to  be  dis- 
charged. A  certain  physical  improvement  usually  takes 
place  rapidly,  but  during  the  interval  which  now  follows  the 
body  weight  frequently  remains  lower  than  it  was  before 
the  onset  of  disease. 

After  a  considerable  number  of  attacks  there  frequently 
occurs   a  considerable,   or  even   lasting,  cessation.     Or  the 


CLINICAL   FORMS  131 

attacks  are  prolonged  and  are  only  interrupted  by  short, 
comparatively  clear  intervals.  In  a  small  number  of  cases 
there  may  finally  be  developed  a  quite  regular  alternation 
lasting  for  decades  between  short  periods  of  the  most  severe 
excitement  and  of  quietness.  In  a  patient  whom  I  observed 
there  had  developed  a  daily  alternation,  setting  in  with  the 
greatest  punctuality  between  behaviour  in  every  way  suitable 
for  society  and  the  most  violent  raving  mania,  which  lasted 
at  least  for  ten  years.  But  it  invariably  comes  to  the 
development  of  marked  psychic  decline,  which  sometimes 
has  more  the  features  of  a  simple  weak-mindedness  with 
poverty  of  thought,  lack  of  judgment,  emotional  dulness  and 
weakness  of  volition,  sometimes  is  accompanied  by  incoher- 
ence and  affectation.  In  contrast  to  the  excess  of  men  in 
the  other  forms,  two-thirds  of  these  patients  were  women, 
in  whom  obviously  the  periodicity  of  sexual  life  favours  the 
development  of  the  form  which  runs  this  course. 

Formerly  I  regarded  these  forms  as  belonging  to  manic- 
depressive  insanity.  Without  doubt  in  this  disease  also  there 
are  attacks  of  similarly  short  duration.  Meanwhile  the  states 
of  excitement  here  described  which  are  repeated  in  short 
periods  of  time  often  form  only  an  episode  in  the  course 
of  a  disease  which  otherwise  undoubtedly  is  dementia 
praecox ;  further,  the  states  of  weakness  which  are  developed, 
bear  the  features  throughout  of  the  decline  geiTerated  by  that 
malady.  These  experiences  have  made  me  change  my 
opinion.  There  is  also  the  fact  that  the  states  of  excitement 
themselves,  with  their  monotony,  impulsive  character,  and 
poverty  of  thought,  resemble  much  more  those  of  dementia 
praecox  than  those  of  mania.  Again  the  circumstance  might 
be  pointed  out,  that  periodic  states  of  excitement  are  also 
otherwise  very  frequent  in  dementia  praecox.  Lastly,  one 
might  bring  forward  the  fact  that  occasionally  inherited 
relationships  can  be  proved  between  this  and  other  forms 
of  dementia  praecox.  Accordingly  one  may  represent  it  to 
oneself  somewhat  in  this  way,  that  a  peculiarity  of  the  malady, 
which  usually  only  develops  later,  dominates  the  clinical 
picture  in  the  cases  here  discussed  specially  early  and  in 
specially  high  degree. 


Catatonia. 

The  states  of  excitement  of  dementia  praecox  form 
also  an  important  constituent  part  of  that  clinical  form 
to  the  consideration  of  which  we  have  now  to  turn,  cata- 


132  DEMENTIA    PRECOX 

tonia.^  Under  this  name  Kahlbaum  has  described  a  clinical 
history  which  presents  in  series  the  symptoms  of  melancholy, 
of  mania,  of  stupor,  also  in  an  unfavourable  course  those  of 
confusion  and  dementia,  and  besides  is  characterized  by  the 
appearance  of  certain  motor  spasmodic  and  inhibitory  pheno- 
mena, just  the  "catatonic"  disorders.  The  description  given 
by  him,  in  many  respects  masterly,  should  demonstrate  that 
all  conditions  till  now  named  melancholia  attonita,  stupor, 
acute  dementia,  and  so  on,  are  in  reality  only  manifestations 
of  a  single  psychosis,  which,  like  dementia  paralytica,  in 
spite  of  external  differences  in  the  course,  still  exhibits  a 
number  of  wholly  peculiar  bodily  and  psychic  morbid 
symptoms. 

As  far  as  we  can  take  a  general  view  of  it  to-day,  the 
statement  of  Kahlbaum  must  be  regarded  in  a  certain 
direction  as  too  narrow  but  in  another  as  too  wide.  Later 
experience  has  taught  that  the  catatonic  morbid  conditions 
can  nowhere  be  sharply  separated  from  the  remaining  forms 
of  dementia  pra:?cox.  Much  rather  not  only  are  certain 
fundamental  features  of  the  clinical  picture  common  to  both, 
but  single  catatonic  morbid  symptoms  frequently  meet  us 
also  in  forms  of  the  disease  otherwise  wholly  divergent. 
As  further  in  all  remaining  respects,  in  the  conditions  of 
development,  in  the  course  and  specially  in  the  issues,  and 
lastly,  so  far  a^  a  judgment  on  the  subject  is  possible  to-day, 
also  in  the  post-mortem  findings,  no  decided  differences  are 
recognizable,  we  may  regard  the  catatonia  of  Kahlbaum  as 
in  the  main  a  form,  though  peculiar,  of  dementia  praecox. 
On  the  other  hand  "  catatonic "  morbid  phenomena  are 
undoubtedly  also  observed  in  many  quite  different  morbid 
processes  to  a  greater  or  less  extent,  so  that  its  appearance 
alone  does  not  justify  the  conclusion  that  catatonia  in  the 
sense  just  indicated  is  present.  In  this  direction  accordingly 
we  must  limit  the  conception  mentioned,  that  only  such  cases 
of  disease  belong  to  it,  in  which  the  morbid  process  of 
dementia  praecox  is  the  foundation.  How  far  and  by  what 
symptoms  we  are  able  already  to  recognize  that  to-day,  must 
be  discussed  later. 

The   course    of   catatonia   in   the   single   periods   above 

'  Kahlbaum,  Die  Kalalonie  oder  das  Spannungsirresein.  1874 ;  Brosius, 
AUgem.  Zeitschr.  f.  Psychiatric,  xxxiii.  770  ;  Neisser,  Uber  die  Katatonie.  1887  ; 
Behr,  Die  F'rage  der  Katatonie  oder  des  Irreseins  mit  Spannung.  Diss.  Dorpat. 
1891  ;  Schiile,  Allgeni.  Zeitschr.  f.  Psychiatrie,  liv.  515,  Iviii.  221  ;  Aschaffen- 
burg,  ebenda,  1004 ;  Meyer,  Archiv.  f.  Psychiatrie  xxxii.  780 ;  Tschisch, 
Monatsschrift  f.  Psychiatrie  vi.  38.  1899  ;  Arndt,  Centralblatt  f.  Psych,  xxv.  81. 
1902  ;  Claus,  Catatonic  et  stupeur.  1903  ;  Pfister,  Allgem.  Zeitschr.  f.  Psychi- 
atrie. 1906,  275. 


CLINICAL   FORMS  133 

mentioned  is,  as  Kahlbaum  himself  has  already  said,  not 
inviolable,  but  it  represents  only  in  a  certain  degree  the 
general  framework,  in  which  the  divergent  cases  approxi- 
mately find  a  place.  The  really  characteristic  pictures  of 
the  state  are  rather  the  "  mania  "  of  Kahlbaum,  which  to-day 
we  more  correctly  name  catatonic  excitement  and  stupor,  I 
think,  therefore,  that  I  may  group  together  as  catatonic  forms 
of  dementia  prctcox  those  cases  in  which  the  conjunction  of 
peculiar  excitement  with  catatonic  stupor  dominates  the  clinical 
picture.  It  is  true  that  states  of  stupor  are  occasionally 
interpolated  for  quite  a  short  time  or  by  slight  indications 
also  in  the  states  of  excitement  hitherto  described.  In  this 
way  gradual  transitions  arise  to  the  catatonic  forms  now 
about  to  be  discussed,  in  which  both  conditions,  apparently 
so  opposed  to  each  other,  come  under  observation  along  with 
or  after  each  other. 

The  development  of  the  disease  takes  place  in  41  per  cent, 
of  the  cases  acutely,  in  31  per  cent,  insidiously,  otherwise 
subacutely.  In  47  per  cent,  of  the  cases  a  state  of  depression 
forms  the  introduction  ;  an  acute  commencement  is  in  these 
cases  somewhat  seldomer.  The  patients  become  reserved,  shy, 
introverted,  absent-minded,  distracted,  indifferent,  irritable, 
taciturn  ;  they  stand  about,  carry  on  unintelligible  conversa- 
tions, pray,  go  often  to  church,  get  up  at  night,  eat  and  sleep 
badly.  At  the  same  time  they  give  utterance  to  a  great 
many  delusions  frequently  quite  extraordinary ;  there  come 
"  temptations,"  "  presentiments."  They  have  evil  thoughts, 
feel  themselves  lost  and  abandoned,  proscribed.  They  feel 
uneasy,  as  if  someone  were  persecuting  them ;  their  life  is 
no  longer  of  any  value ;  everything  has  turned  out  badly ; 
no  one  can  help  them.  They  are  mocked  by  bad  women, 
maligned,  spat  on,  grossly  abused  ;  they  are  to  be  taken  to 
the  convict-prison,  condemned  to  death,  slaughtered,  buckled 
on  to  the  railway  ;  their  house  is  to  be  blown  up ;  their 
family  is  trying  to  take  their  life,  wants  to  be  rid  of  them. 
The  chopping-knives  are  already  being  sharpened ;  people 
are  coming  to  fetch  them  ;  their  daughter  is  being  murdered; 
their  children  are  going  to  the  scaffold.  Everything  is  being 
taken  away ;  the  stove-pipe  is  stopped  up ;  murder  and 
robbery  are  being  committed  on  their  mother.  Their  food 
is  poisoned,  lard  is  in  the  coffee ;  in  the  soup  there  are 
worms  and  human  flesh  ;  poison  is  being  blown  on  them  ; 
the  flies  must  bite  the  patient ;  his  hair  is  being  torn 
out. 

Ideas  of  sin  are  frequently  associated  with  these 
delusions.     The   patient  is  more  wicked  than  Judas    is  the 


134  DEMENTIA    PRECOX 

"  old  eternal  swine,"  a  traitor,  not  worthy  to  look  in  the 
mirror  ;  he  has  led  a  dissolute  life,  has  not  prayed  enough, 
has  nailed  the  Saviour  to  the  Cross,  murdered  his  children, 
is  bringing  everyone  to  misfortune.  He  has  three  evil  spirits 
in  his  head  ;  he  must  always  remain  in  life  because  the  devil 
is  hiding  in  him  ;  he  wishes  to  do  penance.  People  reproach 
him  that  he  has  stolen,  that  he  has  assaulted  a  child  ;  he  is  to 
renounce  his  faith,  is  in  alliance  with  the  evil  one  ;  he  is 
to  get  a  prayer-book  and  holy  water,  is  to  have  his  head 
chopped  off.  Many  patients  defend  themselves  against  the 
supposed  reproaches  ;  they  have  done  nothing,  do  not  want 
to  be  killed.  The  ideas  of  sin  are  expressed  very  clearly  in 
the  following  document  written  by  a  patient : 

"  I  am  a  whole  world  of  mean  actions  and  of  secret  and  open  vice,  I 
believe,  therefore,  that  I  only  do  damage  with  my  filth  of  mean  actions 
and  evil  deeds,  in  short  in  all  domains  just  where  I  am.  I  am  too 
cowardly  to  die  a  hard  death  or  a  lingering  death  and  think  therefore  it 
is  now  about  time  to  die  entirely  by  means  of  a  revolver.  A  noxious 
person  in  every  way,  I  am  really  not  worth  powder  and  shot,  and  have 
never  been  an  iota  of  use  to  you,  on  the  contrary  only  done  you  a 
thousandfold  damage,  just  for  this  reason  away  with  me,  completely 
exterminated." 

Often  a  state  is  developed  of  perplexity  and  confusion. 
Everything  is  enchanted,  changed,  full  of  entanglements  and 
complications,  bewitched  ;  the  patient  believes  that  he  is  in 
an  enchanted  castle,  in  China,  in  heaven  ;  he  fights  battles 
with  death  and  devil.  There  is  war  ;  the  heavens  are  falling  ; 
there  is  a  fire  ;  the  house  is  falling  in  ;  the  end  of  the  world 
is  imminent,  the  Palatinate  is  being  consumed  by  fire.  The 
patient  is  being  made  ill  by  treacherous  people,  does  not 
know  himself  any  more,  feels  himself  "quite  darkened," 
appears  strange  to  himself;  the  furniture  does  not  belong  to 
him  ;  the  visitors  are  not  the  right  people.  He  takes  his 
fellow-patients  for  his  relatives,  for  princes,  the  physician  for 
the  black  devil,  for  Jesus,  for  the  King.  All  human  beings 
have  been  destroyed  ;  there  is  no  one  any  longer  at  home ; 
everything  is  being  taken  away,  the  safe  is  being  broken 
into. 

Hypochondriacal  ideas. — These  occur  very  frequently. 
The  patient  has  pain  in  his  limbs,  pressure  in  his  throat, 
poison  in  his  body,  phthisis,  dropsy,  he  must  die.  His  semen 
has  gone  inwards ;  his  bones  are  growing  out  of  his  body. 
His  feet  are  black,  his  hands  have  rotted  ;  a  patient  thought 
that  he  was  dirty  and  washed  himself  continuously.  His 
stomach  runs  up  and  down ;  blood  forces  its  way  out  at 
mouth  and  nose  ;  fire  issues  from  his  mouth  ;  his  faeces  are 


CLINICAL   FORMS  135 

alive.  His  throat  and  anus  have  closed  up ;  his  h'mbs 
become  smaller ;  his  eyes  have  been  gouged  out  ;  the  patient 
has  a  club-foot,  chloride  of  lime  in  his  bones,  is  full  of  grass 
and  moss,  is  shut  up  with  a  pane  of  glass.  He  suffers  from 
headache,  his  head  is  empty,  he  has  diphtheria  in  his  brain, 
beetles  in  his  head,  cannot  speak  ;  his  memory  has  suffered 
much. 

The  Feeling  of  Influence  also  often  plays  a  part  in  the 
delusions.  The  patients  feel  themselves  "  influenced  by 
magic  power,"  "governed  by  invisible  power."  At  night 
"  electro-magnetic  practices  are  carried  on  "  ;  their  nature  is 
caused  to  pass  from  them  ;  they  are  made  crazy  ;  they  must 
think  filthy  thoughts,  do  what  the  mediums  wish  ;  they  are 
hypnotized  by  the  physician. 

Exaltation. — Here  and  there  ideas  of  exaltation  appear 
beside  those  of  depression.  The  patient  is  Gustavus 
Adolphus,  King  of  Hungary,  a  great  athlete,  will  go  to 
Vienna  and  there  become  Kaiser,  inherits  money  from  his 
fiancee,  gets  60,000  marks  from  God,  wishes  to  marry,  to  go 
to  America  by  the  lightning-express,  to  redeem  mankind, 
to  make  other  laws  ;  he  is  the  emperor-angel,  has  revelations 
in  the  spirit,  wants  milk  from  angels.  Female  patients  are 
"  Queen  on  the  Rhine,"  "  Heaven's  child,"  become  engaged 
to  the  Kaiser,  wish  to  marry  Jesus,  an  officer,  have  a  secret 
love  affair,  are  pregnant,  possess  castles,  ten  millions.  A 
servant  girl  asserted  that  the  son  of  her  employers  had 
offered  70,000  marks  for  her  ;  another  related  that  she  was 
getting  three  crowns  before  her  execution.  Usually  these 
delusions  are  fairly  fleeting  and  indefinite,  and  are  given 
expression  to  without  special  emphasis.  A  patient  said 
he  did  not  know  whether  his  mother  was  Queen  of  England, 
or  Kaiserin,  or  a  cook. 

Hallucinations  are  invariably  present,  especially  those  of 
sight  and  hearing.  The  patients  see  apparitions  of  light, 
figures,  three  faces  at  the  altar,  devils,  dogs,  snakes,  soldiers, 
policemen.  They  hear  music,  voices  of  birds,  cries  for  help, 
voices  from  the  stove  and  water  pipes,  from  their  own  body, 
"  from  the  hind."  There  is  singing  in  the  wall  ;  the  apparatus 
is  crazy  under  the  bed  ;  the  clocks  are  speaking ;  outside 
they  are  blustering  ;  the  Christ-child  speaks ;  their  mother  is 
weeping ;  husband  and  daughter  are  calling  out ;  dogs  are 
barking.  Gentlemen  are  telling  wicked  stories  ;  the  devil 
calls  out  the  name  of  the  patient ;  God  announces  to  him  that 
he  must  die,  carries  on  conversations  with  him  ;  the  Kaiser 
challenges  him  to  a  duel  with  pistols  ;  people  mock  him,  call 


136  DEMENTIA    PRECOX 

him  abusive  names  ;  "  Goose,"  "  Good-for-nothing,"  "  wicked 
fellow,"  threaten  to  tear  out  his  throat ;  a  voice  in  his  head 
reproaches  him.  A  female  patient  perceived  that  she  had  a 
secret  love  affair,  and  said,  "  I  have  that  so  in  hearing." 
Many  patients  have  their  thoughts  said  to  them ;  others 
receive  commands,  "Hands  up";  a  female  patient  heard 
"  all  the  letters  of  the  alphabet,"  and  had  to  count.  Here 
and  there  the  voices  have  a  rhythmical  cadence.  Some 
patients  feel  themselves  breathed  on,  blown  on,  tormented 
with  rays,  electrified,  feel  needles  in  their  hands,  smell  the 
smell  of  corpses  ;  one  patient  stated  that  he  had  "experienced 
much  in  his  genitals." 

States  of  Excitement. — After  the  introductory  depres- 
sion theVe  usually  next  follows  a  state  of  stupor,  especially  in 
men,  and  then  excitement ;  more  rarely  is  it  the  other  way. 
On  the  other  hand  the  cases  setting  in  without  depression 
begin  according  to  my  experience  somewhat  more  frequently 
in  the  form  of  a  state  of  excitement,  the  picture  of  which 
essentially  corresponds  to  that  of  the  agitated  form  previously 
described.  The  patients  become  restless,  sleepless,  run  about, 
carry  on  absurd  conversations  ;  their  actions  are  impulsive 
and  aimless,  and  they  fall  more  or  less  rapidly  into  severe 
excitement  ;  sometimes  raving  mania  may  break  out  quite 
suddenly,  even  in  the  middle  of  the  night,  perhaps  after 
insignificant  prodromal  symptoms  which  have  not  been 
noticed  at  all.  Mood  is  usually  exalted.  The  patients  laugh, 
try  to  be  witty,  make  jokes,  tease  other  patients,  boast,  carry 
on  unrestrained  conversations ;  here  and  there  religious 
ecstasy  is  observed.  But  very  frequently  the  patients  are 
also  irritated,  angry,  threatening  ;  they  break  out  into  wild 
abuse,  fly  into  a  passion  on  the  slightest  occasion,  make 
dangerous  attacks  without  consideration.  More  rarely  they 
are  anxious,  whine,  cry,  groan,  wring  their  hands,  beg  for 
their  life,  scream  "  murder  !  "  "  Satan,  begone  !  "  ;  they  do  not 
wish  to  go  to  the  war ;  they  prepare  for  death.  But  invari- 
ably the  colouring  of  the  mood  is  subjected  to  swift  and 
astonishing  change.  Angry  irritation  is  abruptly  interrupted 
by  a  jocular  remark  ;  the  patient  who  has  just  been  lament- 
ably afraid  of  Satan,  suddenly  calls  out  laughing,  "The 
wicked  one  has  gone ! "  Many  patients  laugh  and  weep 
confusedly,  and  sing  merry  couplets  amid  tears.  Very 
frequently  there  is  extreme  sexual  excitement,  which  is  made 
known  by  jealous  ideas,  shameless  utterances,  movements  of 
coitus,  regardless  exposure  and  masturbation.  A  female 
patient  tore  her  chemises  down  the  front;  others  grasp  at  the 
genitals  of  the  physicians  ;  a  male  patient  tried  to  urinate  on 


CLINICAL   FORMS  137 

a  nurse.     During  the  menses  the  states  of  excitement  usually 
grow  worse. 

While  the  excitement  in  many  cases  only  affects  the 
patients  with  a  certain  restlessness,  we  meet  in  others  the  most 
severe  raving  mania.  .But  even  in  the  same  case  the  most 
violent  excitement  may  very  rapidly  develop  from  nearly 
complete  quiet,  and  then  just  as  suddenly  again  dis- 
appear. 

The  Behaviour  of  the  patients  has  only  a  slight  connec- 
tion with  their  ideas  and  moods.  Anxious  patients  pray, 
kneel,  run  off  by  night,  hide  away  in  the  forest,  try  to  throttle 
themselves,  jump  out  of  the  window  ;  the  irritable  mood  leads 
to  sudden  deeds  of  violence,  megalomania  to  the  squandering 
and  giving  away  of  their  goods  and  chattels,  the  exalted 
mood  to  wonderful  decorations.  A  patient,  who  wished  to 
become  a  poet,  copied  out  Goethe  and  Schiller  with  this  aim 
in  view  ;  another  practised  indoor  gymnastics  "  against  globus 
hystericus  and  psychic  pains." 

As  a  rule,  however,  no  satisfactory  motive  can  be  found 
for  the  activities  of  the  patients,  which  are  often  extremely 
peculiar ;  they  seem  much  rather  to  follow  blindly  whatever 
impulses  may  happen  to  arise  in  them.  They  make  aimless 
journeys,  want  to  go  to  America,  run  about  naked,  clear  out 
the  beds,  destroy  the  stove,  burn  important  papers,  smash 
panes  of  glass,  bite  to  pieces  plates  and  glasses,  suddenly  fall 
round  someone's  neck  and  kiss  him,  and  then  spit  in  his  face 
or  give  him  a  resounding  box  on  the  ear.  They  drag  other 
patients  out  of  bed,  strike  out  senselessly  in  every  direction, 
throw  their  shoes  about,  dance  about  with  the  door  of  the 
room  which  they  have  lifted  off  its  hinges,  gallop  away  buck- 
jumping  in  position  for  fencing,  bite  a  neighbour,  shove  the 
furniture  about  the  room,  take  possession  of  any  object  with 
blind  fury,  climb  hastily  on  to  a  table  or  on  to  the  window-sill 
in  order  to  defaecate  there.  A  female  patient  laid  small 
pieces  of  bread  in  rows  on  the  edge  of  her  bed;  kissed  the 
grating  of  the  hot-air  apparatus  for  hours,  and  dragged  her 
mattress  continually  round  her  in  a  circle,  each  time  at  a 
definite  place  knocking  on  the  wall ;  another  stood  with  arms 
extended  on  the  night-stool  ;  a  third  wished  to  dig  up  her 
dead  father  again ;  a  male  patient,  when  the  party  was 
gathered  together  for  counting,  climbed  up  a  tree,  took  off 
his  clothes,  whistled  and  yodeled. 

Activities. — In  more  severe  excitement  the  activities  of  the 
patients  are  resolved  into  a  disordered  series  of  unconnected 
and  unrelated  impulses.  They  dart  through  the  room  with 
arms  stretched  out  in  front  of  them,  slide  on   the  polished 


138  DEMENTIA    PRECOX 

floor,  run  violently  u{)  and  down  or  round  about  in  small 
circles  so  that  their  track  is  gradually  marked  out  like  that  of 
a  beast  of  prey  in  a  cage.  Others  lie  down  on  their  belly 
and  carry  out  swimming  movements,  glide,  roll  about  on  the 
floor,  frisk  about,  hop,  stamp  with  their  feet,  turn  round  about 
on  their  toes,  drum  with  their  fingers,  throw  out  their  arms, 
grasp  ever)'thing  round  them,  creep  round,  go  a  few  steps 
forward  then  back  again,  lift  up  the  beds,  bite  tight  into  the 
pillows.  At  the  same  time  it  very  commonly  comes  to 
frequent,  rhythmical  repetition  of  the  same  actions  or 
movements.  The  patients  bounce  up  and  down,  swing 
hither  and  thither,  clap  their  hands,  make  arm  movements  of 
exorcising,  drawing  water,  fanning,  turning,  circling ;  they 
revolve  their  fists  round  each  other ;  they  grind  their 
teeth,  lift  their  legs  high,  turn  about,  shrug  their  shoulders, 
throw  their  hair  sometimes  over  their  face,  sometimes  back- 
wards, blink  their  eyelids,  squint,  breathe  with  forced  breaths, 
pant,  blow,  nod,  seize,  pull,  pick,  rub  their  hands,  tap  on  the 
table. 

Remains  of  such  stereotypies  are  usually  preserved  in  the 
terminal  states.  To  them  are  related  all  kinds  of  monotonous 
repeated  actions  which  may  become  habits  very  difficult  to 
root  up.  Many  patients  pull  their  clothes  to  pieces,  bite  their 
nails,  scrape  the  lime  from  the  walls,  collect  rubbish  in  their 
pockets,  tie  threads  round  their  fingers  or  genitals,  devour 
buttons  and  stones,  stick  objects  in  their  ears,  burn  themselves 
with  their  cigar,  tear  and  scratch  definite  parts.  A  patient 
perpetually  destroyed  his  shirt  buttons  in  order  to  bore  the 
little  metal  ring  through  the  lobes  of  his  ears.  Here  also 
belongs  probably  the  continual  spitting  which  sometimes 
threatens  the  whole  surroundings  ;  a  patient  said  that  he  did 
"  saliva  gymnastics." 

Besides  stereotypy  we  invariably  meet  in  the  activities  of 
the  patients  indications  of  the  volitional  disorders  formerly 
discussed.  Automatic  obedience  is  shown  in  the  distractibility 
of  the  patients ;  they  weave  words  they  hear  into  their 
conversation,  join  in  other  people's  singing,  sometimes  take 
part  in  everything  that  goes  on  round  them.  They  are 
frequently  cataleptic,  occasionally  also  echolalic  or  echopractic. 
In  other  patients  or  at  other  times  negativistic  features  are 
more  in  evidence.  The  patients  do  not  trouble  themselves  in 
the  least  about  their  surroundings,  give  no  answers  to 
questions,  do  not  shake  hands,  do  not  let  themselves  be 
influenced  in  any  way  in  their  doings,  resist  every  interference, 
force  their  way  out  senselessly,  knock  or  push  with  their 
knees  against  the  doors.     They  throw  their  food  away,  lie 


CLINICAL  FORMS  139 

• 

down  in  other  people's  beds,  He  in  a  slanting  direction,  give  a 
wrong  name,  do  everything  differently  from  what  one  expects. 
A  patient  knocked  over  the  table  and  then  sat  down  on  the  top. 

The  circumstance  that  the  excitement,  even  when  ex- 
tremely violent,  frequently  takes  place  within  the  smallest 
space,  is  up  to  a  certain  point  characteristic  of  the  states  here 
described.  The  patients  have  not  as  a  rule  any  tendency  to  in- 
fluence their  surroundings,  but  their  restlessness  exhausts  itself 
in  wholly  aimless  activity  which  on  this  account  also  needs  no 
extended  stage.  The  movements  themselves  are  sometimes 
clumsy  and  uncouth,  sometimes  jerky,  angular  or  affected, 
solemn,  then  again  unusually  nimble  and  quick  as  lightning. 
Side  impulses  are  frequently  interpolated.  The  patients  eat 
with  the  handle  of  the  spoon,  give  the  hand  turned  the  wrong 
way,  walk  stiffly  "as  if  they  were  marching  tnrough  snow," 
lifting  their  feet  high,  urinate  behind  the  bed. 

Usually  all  their  actions  are  carried  out  with  great  strength 
and  without  any  consideration,  so  that  it  is  scarcely  possible 
to  prevent  them.  "Go  away!  I  must  drag  the  mattress ;  I 
must  knock  at  the  door,"  a  female  patient  cried  out ;  she  gave 
the  word  of  command,  "  Stand  up  !  Fall  down  !  "  innumerable 
times,  as  she  let  herself  fall  and  got  up  again.  In  consequence 
of  these  doings  it  sometimes  comes  to  abrasions  of  enormous 
extent,  to  more  or  less  serious  injuries,  as  the  patient  does 
not  spare  his  limbs  in  the  slightest,  always  knocks  the  injured 
parts  again,  and  without  more  ado  tears  away  the  bandages 
which  hinder  him.  Not  infrequently  the  patients  injure 
themselves  in  the  most  serious  way.  They  box  their  ears 
right  and  left  for  hours,  dash  themselves  headlong  on  the 
floor,  try  to  squeeze  in  their  neck,  to  tear  out  their  penis,  bite 
their  arm,  tear  their  hair,  scratch  themselves,  pick  at  their 
fingers,  bruise  their  tongue  and  their  underlip  with  their  teeth, 
beat  themselves  on  the  head,  tear  out  their  toe-nails ;  a 
patient  bit  off  the  tip  of  his  finger.  Now  and  then  also 
impulsive  attempts  at  suicide  are  made. 

The  Bodily  Care  of  the  patients  encounters  in  these  cir- 
cumstances the  greatest  difficulties.  As  a  rule  they  are  very 
dirty.  They  pass  their  motions  under  them,  roll  up  their 
faeces  in  balls,  devour  them,  lick  up  their  urine  from  the  floor, 
urinate  into  the  spittoon,  smear  themselves  with  menstrual 
blood,  put  bread  in  their  anus,  spit  into  their  hands,  into  the 
soup,  on  their  bread  and  butter,  in  their  own  bed.  They 
sometimes  eat  greedily,  swallowing  down  their  food  unchewed 
with  haste  in  incredible  quantity,  and  even  taking  away  their 
neighbours'  food  ;  sometimes  they  struggle  to  the  utmost 
against  the  taking  of  any  nourishment,  spit  everything  out 


I40  DEMENTIA    PR.CCOX 

again,  even  what  they  begged  for  before  with  entreaties. 
Many  patients  only  eat  when  they  think  they  are  unobserved, 
or  they  let  the  food  stand  for  hours  till  it  has  become  cold 
and  almost  uneatable. 

Movements  of  expression  usually  undergo  very  varied 
and  singular  changes.  Here  belong  spreading  gestures, 
making  faces,  threatening  flourishes,  senseless  shaking  and 
nodding  of  the  head,  monotonous  crying,  crowing,  yodeling, 
clicking,  spitting  like  a  cat,  singing,  squeaking,  screaming  in 
falsetto,  screeching  and  growling,  and  continuous,  uncontroll- 
able laughter.  Speech  is  sometimes  scanning,  rhythmical, 
with  wholly  perverted  intonation,  sometimes  singing  or  com- 
manding, sometimes  jerky,  sometimes  in  broken  sentences. 
Many  patients  declaim  in  the  high-sounding  cadence  of  the 
actor,  hold  discourses,  preach  with  lively  movements  of 
expression  and  mingling  of  religious  phrases,  or  they  hastily 
bubble  over  with  unintelligible  words,  sometimes  in  foreign 
or  self-invented  speech.  Other  patients  whisper  and  murmur, 
grunt  or  scream  with  all  their  might.  One  patient  barked 
for  hours  like  a  dog.  Some  patients  speak  through  their 
nose,  affectedly,  in  an  intentionally  coarse  or  silly  manner, 
like  small  children,  without  construction  into  sentences,  in 
infinitives  ;  they  turn  the  words  about,  use  diminutives 
everywhere.  To  this  are  added  neologisms,  and  sought-out 
expressions  ;  a  female  patient  spoke  of  "  poison  blisters." 
The  substance  of  the  conversations  often  shows  a  high 
degree  of  incoherence  ;  the  following  sentences  furnish  an 
example  of  this  : 

"  But  I  cannot  let  myself  be  made  mad  and  dad.  You  know  I  was 
quite  mad  and  perhaps  am  so  still.  Whether  it  is  a  Lord  Grand  Duke 
or  King  and  Kaiser — whether  it  is  the  voice  of  the  court  or  who  it  is. 
The  dear  God  in  heaven  comes  as  well  and  if  it  is  only  a  dog  or  a  gnat 
— or  a  little  bit  of  bread.  I  don't  know  whether  I  have  a  fish  in  my 
hand  or  a  serpent  or  what  rattles  or  what  walks  and  stands  ;  I  should 
prefer  everything  in  the  world.  From  below  ami  above  no  one  can  be 
made  mad."  "  My  nose  belongs  now  stuffed  into  Jesus  Christ  and 
everything  twisted  round  me.  They  all  rattle  and  mock  God.  And  if 
the  dear  .Arch-Grand  Duke  is  up  there,  then  those  on  this  side  and  that 
side  mock  and  ridicule  and  put  sleekness  in." 

There  are  to  be  noticed  here  the  neologisms,  the  repeti- 
tion of  single  exi)ressions,  "be  made  mad,"  "rattle,"  "mock," 
the  senseless  similarities  of  sound,  the  lack  of  all  connection 
of  ideas  in  sustained  construction,  lastly  the  indications 
of  exalted  ideas  and  of  morbid  feeling. 

Verbigeration. — Lastly  the  phenomenon,  already  dis- 
cussed, of  verbigeration  is  very  common.  Sentences  of  any 
length,  frequently  wholly  senseless  (for  example  "  Gekreuzig- 


0 

CLINICAL   FORMS  141 

ter  Krex  in  e  Umkrexhaus  "),  also  perhaps  single  letters  are 
repeated  for  hours  and  days  without  interruption  in  the  same, 
often  rhythmical,  intonation,  sometimes  screaming,  sometimes 
whispering,  sometimes  even  in  a  definite  tune.  A  female 
patient  called  out  fifty  times  in  succession  "  Up  !  "  Some- 
times the  patients  make  slips  in  speaking  or  a  word  heard  in 
the  surroundings  is  interpolated  ;  in  this  way  a  sentence  may 
gradually  undergo  changes,  the  result  of  which  then  appears 
after  some  hours.  One  can  often  force  the  patients  to  repeat 
their  accustomed  sentences  by  saying  the  beginning  to  them. 
Thus  a  quite  sensible  patient  for  weeks,  on  the  cue  "  My 
husband  "  being  given  in  the  middle  of  a  conversation,  con- 
tinued the  sentence  in  drawling  cadence  without  hesitation, 
though  frequently  against  her  will : 

"  My  husband  is  a  fine  man,  a  cultured,  respected,  diligent,  honest 
merchant,  and  1  am  his  wife  ;  my  child  is  an  honest  child,  and  we  have 
no  debts  in  the  town,  and  we  have  2000  marks  of  honest  money,  and 
300  marks,  these  we  found.  My  brothers  and  sisters  are  honourable 
brothers  and  sisters,  and  my  brothers  are  respected,  diligent,  esteemed, 
honest  men  of  business,  and  that  is  the  pure  truth." 

To  the  question  why  she  always  repeated  this  speech,  she 
said,  "because  I  am  cracked."  In  other  cases  the  substance 
of  the  verbigerative  speeches  shows  great  variety.  In  the 
writings  of  the  patients  also  we  meet  with  disconnectedness 
and  incoherence  of  the  substance,  and  the  tendency  to 
bewildering  desultoriness,  to  sounding  phrases  that  say 
nothing,  endless  enumerations,  uniform  repetitions,  to  odd 
figures  of  speech  and  neologisms.  Many  patients  write  non- 
sensical whirligigs  and  assert  that  this  is  a  foreign 
language. 

Stupor. — In  the  further  course  of  the  disease  states  of 
stupor  follow  the  excitement  ;  somewhat  seldomer  they 
precede,  with  or  without  introductory  depression.  The 
patients  become  quiet,  shy,  monosyllabic,  sink  into  brooding, 
stare  fixedly  in  front  of  them,  stand  about  in  corners,  hide 
themselves  and  creep  out  of  sight,  lie  idly  in  bed  ;  a  patient 
lay  down  "  in  order  meantime  just  to  have  a  good  rest," 
Now  and  then  stupor  begins  quite  suddenly ;  the  patients 
become  mute,  rigid  in  their  whole  body,  sink  on  to  the  floor, 
.  remain  lying  in  cruciform  attitude  with  closed  or  widely  open 
eyes.  All  independent  volitional  expression  is  silent ;  speech, 
the  taking  of  food,  intercourse  with  the  surroundings,  occupa- 
tion, care  for  their  own  needs,  cease  more  or  less  completely. 

External  Influences. — The  behaviour  of  the  patients 
towards  external  influences  shows,  however,  certain  differ- 
ences, which  indeed  are  subject  to. much  variation.     They 


142  DEMENTIA    PRECOX 

are  in  general  characterized  by  the  predominance  either  of 
automatic  obedience  or  of  negativism.  If  one  will,  one  may 
accordingly  separate  out  a  flaccid  and  a  rigid  stupor.  In  the 
first  case  we  principally  observe  catalepsy  lasting  for  shorter 
or  longer  periods,  which  in  such  states  usually  reaches  its 
highest  development.  Echolalia,  or  even  echopraxis,  meet  us 
also,  but  more  rarely  and  usually  only  as  passing  phases. 
The  patients  then  merely  repeat  quite  mechanically  what  is 
said  to  them,  or  even  anything  they  have  picked  up  by 
chance,  in  certain  circumstances  even  with  closed  mouth,  or 
join  in  a  song  which  their  neighbours  are  singing.  Related 
to  this  phenomenon  is  the  constrained  answering  with  an 
association  or  a  jerky  movement,  standing  up  and  sitting 
down,  making  faces,  a  turn  of  the  hand  when  one  calls  to 
them.  The  patients  often  imitate  vivacious  gestures  made  in 
an  impressive  way  in  front  of  them  (lifting  up  the  arms,  clap- 
ping hands),  continue  for  a  considerable  time  a  movement 
stimulated  by  external  influence  (beating  time,  rolling  their 
hands  round  each  other).  Sometimes  they  are  even  seen  for 
hours  doing  everything  that  some  one  person  does  in  their 
surroundings,  saying  everything  that  he  says,  walking  behind 
him  keeping  step,  dressing  and  undressing  along  with  him 
and  so  on.  Some  patients  scream  at  fixed  times ;  others 
give  the  word  of  command  at  tube-feeding:  "  Basin,  tube  and 
glass  utensils,  all  here,  all  here,  Doctor,  feeding,"  "  Mouth 
open,"  "  Tube  clean  ! "  A  female  patient  verbigerated  :  "  Put 
on  nightdress,  lie  .down  in  bed,  bath  !  Put  on  nightdress, 
bath,  lie  down  in  bed  ! " 

The  severe  volitional  disorder  in  these  states  appears  very 
distinctly  when  one  asks  the  patients  to  show  their  tongue 
in  order  to  pierce  it  through  with  a  needle.  Although  they 
notice  the  threatening  needle  and  comprehend  quite  well 
what  is  before  them,  they  still  unhesitatingly  stretch  out  the 
tongue  on  being  asked  emphatically  to  do  so.  In  many 
cases  the  experiment  may  be  made  as  often  as  one  likes  with 
the  same  result.  The  patients  make  a  pitiful  face  at  each 
prick,  but  are  unable  to  suppress  the  impulse  discharged  by 
renewed  command  or  in  any  other  way  to  withdraw  them- 
selves from  the  threatening  injury. 

Rigid  shutting  up  of  themselves  to  all  influences  from 
their  surroundings  is  more  frequent  in  stupor  than  heightened 
susceptibility  to  influence.  The  patients  withdraw  them- 
selves, cover  themselves  up,  press  their  hands  against  their 
face,  hold  their  handkerchief  over  their  mouth,  draw  the 
cover  over  their  head  ;  they  give  no  answer,  do  not  look  up 
when  spoken  to,  do  not  ward  off  pricks  of  a  needle.     Only 


CLINICAL   FORMS 


143 


rarely  does  a  very  strong  stimulus  bring  about  movements 
of  evasion,  still  more  rarely  an  unexpectedly  dextrous  and 
powerful  assault.  Also  an  occasional  slight  blinking,  more 
marked  flushing  or  perspiring  of  the  face,  twitching  of  the 
corners  of  the  mouth   on  such  attempts,  bursts  of  laughter 


Fig.  26.     Stuporous  patient  lying  on  the  edge  of  the  bed. 


when  something  funny  happens,  point  to  the  fact  that  not 
the  perception  of  impressions  but  the  discharge  of  the  corre- 
sponding volitional  expressions  is  disordered.  Commands 
are  not  obeyed  or  only  after  very  long  persuasion  or  with 
vigorous  help.  Sometimes  one  sees  here  and  likewise  in  the 
few  independent  volitional  expressions  of  the  patients  that  a 
movement  is  at  first  begun  correctly,  but  then  suddenly 
interrupted  or  even  turned  into  its  opposite.     Now  and  then 


144  DEMENTIA    PRECOX 

the  negativistic  movements  are  even  set  in  action  by  spoken 
commands.  It  is  then  not  only  possible  to  cause  the  patient 
to  go  forward  by  apparently  forcing  him  back  and  vice  versa, 
but  he  sits  down  on  the  night-stool  if  he  is  definitely  for- 
bidden to  do  it,  stands  still,  as  soon  as  he  is  told  to  go,  lets 
go  if  he  is  commanded  to  hold  fast. 

Also  in  a  series  of  other  features  the  fundamental  resist- 
ance to  the  natural  volitional  impulses  can  be  distinctly 
recognized.  Many  patients  do  not  tolerate  any  clothes  or 
shoes,  not  even  a  shirt,  do  not  go  to  bed,  stand  beside  it  with 
their  arms  folded,  at  night  lie  down  on  the  floor,  under  the 
bed,  on  the  outermost  edge  of  the  bed,  like  the  patient 
represented  in  Fig.  26.  They  put  on  articles  of  clothing  the 
wrong  way,  turn  the  bedclothes  about,  lie  on  the  bedstead 
and  cover  themselves  with  the  mattress,  lie  down  in  another 
person's  bed  or  at  least  stretch  out  their  legs  over  it.  Without 
a  word  they  force  their  way  out  at  a  certain  door,  even  if  all 
the  others  are  standing  open,  but  do  not  use  the  key  which 
is  put  into  their  hand  to  open  it ;  they  go  backwards  if  any- 
one approaches  them,  hide  themselves  in  a  corner,  put  on 
other  people's  clothes,  blindfold  themselves,  throw  their 
petticoats  over  their  head,  do  not  let  anything  be  taken  from 
them  which  they  have  once  taken  hold  of. 

Sometimes  in  spite  of  their  immobility  otherwise  and 
inaccessibility  the  patients  carry  out  single  senseless,  often 
rhythmic  movements,  tap  on  the  table  or  on  paper,  pull  faces, 
move  their  fingers  as  if  playing  the  piano.  Some  patients  do 
not  speak  a  syllable  for  years  or  even  for  decades,  or  they 
just  whisper  now  and  then  some  detached  words,  mostly 
incomprehensible ;  a  patient  suddenly  said ;  "  Let  me  to 
Heaven's  ladder,"  and  then  was  again  mute.  Sometimes 
these  mute  patients  express  themselves  by  writing  in  a  long- 
winded  and  incoherent  way.  Others  on  great  persuasion  only 
move  their  lips,  or  they  give  short  answers,  stick  to  single 
words,  break  off  in  the  middle  of  a  word  or  sentence,  begin  to 
speak  when  one  goes  away,  and  are  silent  as  soon  as  one 
turns  to  them  again.  Their  words  are  usually  brought  out 
in  a  low  voice,  monotonously,  sometimes  jerkily. 

The  taking  of  food  often  encounters  the  greatest  diflficulties. 
The  patients  sometimes  quite  suddenly  stop  eating,  and 
cannot  be  prevailed  on  in  any  way  to  continue  the  meal,  they 
spasmodically  clench  their  teeth,  press  their  lips  together,  as 
soon  as  the  spoon  is  brought  near.  They  keep  the  morsel  that 
is  put  in  their  mouth  there  for  a  long  time,  do  not  chew  it  or 
swallow  it,  let  the  soup  run  out  again.  Often  the  patients  do 
not  eat  as  long  as  they  are  watched,  let  everything  stand  for 


CLINICAL   FORMS  145 

hours,  or  only  take  something  secretly.  Some  patients  with 
invincible  stubbornness  refuse  soup,  meat,  or  the  food  placed 
ready  for  them,  but  know  how  to  procure  by  cunning  or  by 
force  their  neighbours'  food  and  devour  it  with  the  greatest 
haste;  others  again  only  take  certain  dishes;  a  ferhale 
patient  for  days  and  days  called  out  pitifully  and  monoton- 
ously :  "Choc'lat!" 

Faeces  and  urine  are  often  retained  to  the  uttermost.  The 
patients  do  not  use  the  water-closet  at  all,  even  when  they 
are  ever  so  often  taken  to  it,  but  evacuate  immediately 
afterwards  on  the  floor  or  in  bed  and  do  not  change  their 
position  in  the  slightest  to  avoid  the  unpleasant  consequences, 
or  they  remain  lying  on  the  full  bed-pan.  Some  patients 
squeeze  their  urethra  spasmodically  with  their  fingers.  Their 
saliva  is  not  swallowed,  but  collects  in  their  mouth  and  then 
flows  down  over  their  chin  and  clothes  or  suddenly  gushes 
forth  like  a  fountain  from  the  full  cheeks. 

In  the  most  severe  cases  of  negativistic  stupor  the  patients 
usually  lie  in  bed  completely  motionless  and  dumb.  At 
every  attempt  to  change  their  position  all  the  muscles  pass 
into  a  state  of  extreme  tension  and  offer  the  strongest  passive 
resistance,  a  phenomenon  which  caused  Kahlbaum  to  adopt 
the  term  "tension-insanity,"  "catatonia."  If  one  presses 
against  their  forehead  their  head  springs  forward  like  elastic 
as  soon  as  one  lets  go  ;  if  one  touches  the  back  of  the  head, 
it  endeavours  to  go  backwards  against  the  pressure  of  the 
finger.  If  the  patient  is  pushed  from  the  place  where  he  is, 
he  resists  till  he  has  quite  lost  his  equilibrium  and  he  immedi- 
ately takes  up  his  place  again  as  soon  as  the  force  ceases 
to  act.  The  patients  are  often  seen  for  days,  weeks,  even 
for  many  months  assuming  exactly  the  same  position  at  the 
same  place.  They  squat,  kneel,  or  lie  motionless  on  the  spot 
in  a  peculiar  attitude,  like  a  statue,  often  rigidly  twisted  on 
themselves,  in  knee-elbow  position,  their  chin  forced  down 
on  their  breast,  their  head  lifted  up  free  of  the  pillow  or 
hanging  down  over  the  edge  of  the  bed,  the  pillow  over  their 
face,  their  legs  under  the  mattress,  or  the  sheet  between  their  • 
teeth,  spasmodically  grasping  with  their  fingers  perhaps  an 
old  bit  of  bread,  a  ball  of  faeces,  a  button  that  has  been  torn 
off,  a  wreath  of  roses.  They  let  themselves  be  rolled  about  to 
any  extent  or  even  be  lifted  up  in  the  air  like  a  parcel  by  any 
part  of  the  body  without  changing  the  position  of  their  limbs 
in  any  way.  One  of  my  patients  folded  her  hands  spas- 
modically for  such  a  long  time  that  gangrene  arose  at  the 
points  of  contact ;  another  knelt  for  years  on  the  same  spot 
till  he  had  to  be  forcibly  kept  in  bed  amid  violent  struggling 

K 


146 


DEMENTIA   PRECOX 


Fig.  27.     Contracture  of  fingers  in  catal(inia. 


1  %■  22$.     Stuporous  patient. 


CLINICAL  FORMS 


147 


Fig.  29. 
Expression  of  face  in  catatonic  stupor  (a). 


on  account  of  developing  arthritis.  A  patient  sat  bent  for- 
wards in  such  a  way  that 
her  nose  dipped  in  the 
soup;  another  held  the  left 
thumb  always  extended, 
the  right  bent  inwards ;  a 
third  sat  with  the  mouth 
open,  the  tongue  stuck  in 
a  corner  of  the  mouth. 
Many  patients  assume  a 
fencing  attitude;  a  patient 
continually  held  his  hands 
as  if  he  wanted  to  box. 
Sometimes  contractures 
are  developed  in  the  joints 
that  are  continually  bent; 
an  example  of  this  is  given 
in  Fig.  27,  which  represents 
a  patient  who  for  long 
years  had  held  his  arms 
pressed  against  his  body 
and  his  fingers  bent. 

In  stupor  the  eyes  are 
either  closed,  as  in  the  patient  represented  in  Fig.  28;  if 
anything  comes  near  they 
are  tightly  closed  and  the 
eyeballs  rolled  upwards,  or 
they  are  wide  open,  staring 
with  dilated  pupils  into  the 
distance,  never  fixing  any- 
thing; blepharoplegia  takes 
place  extremely  seldom.  The 
forehead  is  drawn  up,  fre- 
quently wrinkled  ;  the  ex- 
pression of  the  face,  vacant, 
immobile,  like  a  mask,  aston- 
ished, is  sometimes  reminis- 
cent of  the  rigid  smile  of  the 
^ginetans.  Figs.  29  and  30 
represent  the  face  of  the 
same  youthful  patient  at 
different  stages  of  a  severe 
catatonic  stupor.  In  the 
former  the  face  shows  more 
a  dazed,  rigid  perplexity,  in 
the  latter  that  sleepy  vacancy 


Fig.  30. 
Expression  of  face  in  catatonic  stupor  {d). 


148  DEMENTIA    PRECOX 

which  is  generally  connected,  as  also  here,  with  catalepsy. 
The  lips  are  often  pursed  forward  like  a  snout  ("  Snout- 
cramp"),  and  show  now  and  then  lightning  or  rhythmic 
twitchings.  Grinning,  sudden  laughter,  and  making  faces  are 
frequent. 

Constraint  is  also  noticeable  in  the  gait  of  the  patients. 
Often  indeed  it  is  quite  impossible  to  succeed  in  experiments 
in  walking.  The  patients  simply  let  themselves  fall  down 
stiffly,  as  soon  as  one  tries  to  place  them  on  their  feet.  In 
other  cases  they  march  with  extended  knees,  on  tiptoe,  on 
the  outer  edge  of  the  foot,  with  legs  wide  apart,  with  the 
upper  part  of  the  body  well  bent  backwards,  sliding,  frisking 
about,  balancing,  in  short,  in  any  wholly  unusual  attitude 
which,  however,  is  preserved  with  all  the  strength  at  their 
command  in  spite  of  every  external  influence.  A  patient 
walked  with  his  face  turned  backwards ;  a  female  patient 
kept  accurately  to  a  seam  in  the  floor  and  did  not  let  herself 
be  pushed  to  the  side.  Single  movements  are  stiff,  slow, 
forced,  as  if  a  certain  resistance  had  to  be  overcome,  or  they 
are  done  jerkily  and  then  often  as  quick  as  lightning. 

The  states  of  catatonic  excitement  and  of  stupor,  which 
are  here  described,  and  which  are  apparently  so  opposed,  are 
obviously  very  tiearly  related  to  each  other  clinically,  as  they 
not  only  can  pass  directly  the  one  into  the  other  but  are  also 
intermingled  in  the  most  varied  way.  The  patient  who  has 
just  been  senselessly  excited  may  suddenly  become  mute  and 
now  lie  motionless ;  the  patient  who  has  been  stuporous, 
perhaps  for  weeks,  abruptly  begins  to  utter  unintelligible 
screams  at  the  top  of  his  voice,  to  call  out  cock-a-doodle-doo, 
to  bark,  to  sing  a  song  in  a  refined  voice.  Or  he  leaps  with 
long  bounds  through  the  roorn,  as  quick  as  lightning  unhinges 
somewhere  or  other  a  window,  gives  a  neighbour  a  box  on 
the  ear,  and  dashes  with  tremendous  force  into  another 
patient's  bed,  and  then  remains  again  inaccessible  or  possibly 
even  passes  through  a  longer  period  of  excitement.  Such  a 
change  of  state  occurs  with  fair  frequency  in  our  patients. 
Very  often  both  excitement  and  stupor  last  only  a  few  days 
or  weeks,  perhaps  only  a  few  hours,  and  then  gradually  or 
suddenly  disappear.  But  on  the  other  hand  also  a  uniform 
clinical  state  may  continue  for  months,  years,  and  even 
decades,  and  be  only  quite  temporarily  interrupted  by 
remissions  or  by  some  other  kind  of  morbid  phenomena. 
Especially  in  stupor  that  happens  not  very  rarely,  while 
catatonic  excitement  stretching  similarly  over  years  belongs, 
one  may  say,  to  the  exceptional  cases. 

The  character  of  the  phenomena  is  in  different  cases  very 


CLINICAL  FORMS  149 

varied.  Stupor  may  sometimes  only  be  indicated  by 
■  taciturn,  repellent  drowsy  conduct,  rising  in  other  cases  to 
the  suppression  of  volitional  discharge,  while  excitement 
may  fluctuate  from  slight,  silly  merriment  to  the  most  regard- 
less fury  seriously  endangering  life.  We  may  well  regard 
it  as  a  mixture  of  the  phenomena  of  both  states  when  a 
patient  dances  about  mute  and  with  closed  eyes,  or  lies 
motionless  and  bawls  a  street  song.  Indeed,  one  may  perhaps 
on  the  whole  connect  the  negativistic  admixtures  in  the 
states  of  excitement,  the  inaccessibility  and  the  insuscepti- 
bility to  influence,  the  resistance,  the  speaking  past  a  subject, 
further  the  indications  of  automatic  obedience,  with  the 
admixture  of  stuporous  morbid  symptoms.  On  the  other 
hand  we  observe  in  stuporous  patients  frequently  enough 
single  impulsive  actions  which  are  otherwise  peculiar  to  the 
states  of  excitement.  The  patients  suddenly  throw  a  cup 
across  the  room,  jump  up  in  order  to  smash  a  pane  of  glass, 
to  go  round  the  table,  to  throw  themselves  then  head  fore- 
most again  into  bed  and  lie  there  motionless,  or  they  give 
utterance  to  meaningless  sounds  or  scream,  hurrah !  The 
stereotyped  movements,  which  are  occasionally  observed  in 
stupor,  fiddling,  pulling  faces,  spitting,  might  also  be  regarded 
from  the  point  of  view  of  a  mixture  with  the  phenomena 
of  excitement.  From  that,  however,  not  much  is  gained. 
Essentially  it  only  appears  that  we  everywhere  meet  the  same 
fundamental  disorders  in  the  different  forms  of  dementia 
praecox  and  so  also  in  the  catatonic  forms,  certainly  in  very 
varied  conjunctions,  even  though  the  clinical  picture  may 
appear  at  first  sight  ever  so  divergent. 

Consciousness  is  for  the  most  part  somewhat  clouded, 
sometimes  even  very  considerably,  in  catatonic  morbid  states, 
especially  during  their  development  and  at  the  height  of 
acute  disorder.  The  patients  appear,  it  is  true,  almost  always 
to  perceive  single  impressions  fairly  well,  even  when  one 
cannot  prove  it  at  first,  but  still  they  usually  have  only  a 
rather  indistinct  idea  of  their  situation  and  of  the  occurrences 
in  their  surroundings,  certainly  partly  on  account  of  the  fact, 
that  they  are  not  at  all  concerned  about  them  and  do  not 
feel  the  need  to  work  up  their  perceptions  further.  They, 
therefore,  often  mistake  people,  do  not  know  where  they  are, 
but  cause  surprise  not  infrequently  by  knowing  the  names 
of  the  nurses  or  of  the  other  patients,  by  making  a  jocular 
remark,  by  complaining  about  some  occurrence  or  other, 
by  giving  a  reasonable  account  of  their  circumstances,  by 
composing  a  connected  letter  with  an  accurate  account  of 
their   place   of  abode   and   the  request  to   be  taken  away. 


I50  DEMENTIA   PRECOX 

Many  patients  also  solve  arithmetical  exercises  correctly, 
even  of  a  somewhat  difficult  kind  and  display  surprising 
knowledge ;  an  apparently  quite  obtuse  and  inaccessible 
country  lad  could  give  accurate  accounts  of  the  Crusades  and 
of  Konradin  of  Hohenstaufen.  Quite  commonly  discernment 
and  clearness  are  much  less  disordered  than  one  is  inclined 
to  assume  from  the  singular  demeanour  of  the  patients  which 
is  essentially  dependent  on  volitional  disorders. 

Insight. — Even  a  certain  insight  into  their  diseased  state 
is  frequently  present.  The  patients  call  their  singular  doings 
stupidity  ;  they  say  that  they  are  just  mad.  To  the  question 
whether  he  was  mentally  affected,  a  patient  replied,  "  Yes,  of 
course  !  If  one  is  sensible,  one  does  not  do  such  things  !  "  A 
female  patient,  who  displayed  catatonic  stereotypies  of 
movement  in  the  highest  degree,  said  to  me,  "  But  I  must 
always  make  such  stupid  movements  ;  it  is  really  too  silly  "  ; 
another  complained  that  she  always  had  to  make  faces,  her 
laughing  should  be  driven  away.  Many  lay  stress  upon  the 
fact  that  when  they  laugh  they  do  not  feel  at  all  merry.  A 
satisfactory  account  of  the  motives  for  their  singular  behaviour 
is  certainly  never  got  from  the  patients.  A  patient  gave  as 
the  motive  of  his  mutism  the  answer,  "  I  am  not  yet  suitable 
to  be  able  to  show  a  voice "  ;  another  stated  that  he  had 
given  utterance  to  his  thoughts  only  in  writing  because  he 
could  not  at  once  find  words  ;  a  third  said  he  had  not  spoken 
because  he  knew  no  one.  A  female  patient  said  that  she  had 
not  wished  to  speak,  another  that  she  did  not  venture  to 
speak.  The  physicians  had  already  known  everything,  the 
questions  had  been  so  simple,  they  had  not  known  what  they 
should  say,  are  similar  utterances.  On  being  asked  the 
motive  of  her  refusing  to  eat,  a  patient  declared  that  she 
simply  did  not  need  to  eat;  another  asserted  that  she  had  not 
been  hungry.  Usually  one  is  told  that  the  patients  were 
obliged  to  do  what  they  did  ;  "  was  obliged  to  spit "  said  a 
patient.  Another  declared  that  she  was  obliged  to  speak  so, 
it  was  given  to  her  so ;  a  third  on  being  asked  why  she 
assumed  such  peculiar  attitudes  answered,  "  Because  I  wish 
to."  Similarly  a  patient  declared  that  he  had  remained  so 
motionless  because  he  had  wished  it ;  another  alleged  that  he 
had  been  obliged  to  behave  in  that  way,  he  had  been 
unconscious.  It  had  just  amused  them,  come  into  their  head, 
they  had  thought  it  had  to  be  so,  a  power,  an  impulse,  a  force 
had  come  over  them,  are  answers  that  frequently  recur. 
Automatic  obedience  is  explained  by  the  fact,  that  it  had  just 
been  wished  so,  that  the  patients  had  thought  that  they  were 
doing  the  physician  a  pleasure. 


CLINICAL   FORMS  151 

Much  more  rarely  are  other  motives  alleged.  A  patient 
according  to  his  own  account  had  believed  that  he  would 
apostatize  from  God  if  he  ate ;  a  female  patient  said  that  God 
had  not  wished  it ;  another  said  that  he  had  been  drawn  to 
his  violent  movements  "  as  with  a  rope,"  a  third  who  in 
counting  always  left  out  the  number  four,  said  that  he  always 
had  to  think  at  the  same  time  of  the  fourth  commandment. 
A  fourth  who  for  hours  played  passionately  on  the  mouth- 
harmonica,  affirmed  that  the  omnipotence  of  God  inspired 
him  to  make  music  in  order  that  the  military  should  take  no 
harm.  It  can  be  clearly  enough  recognized  from  all  these 
alleged  motives,  that  the  singular  actions  are  of  impulsive 
origin  and  do  not  depend  on  definite  deliberation. 

In  spite  of  these  clear  statements  about  the  peculiarity  of 
their  condition  which  in  general  is  usually  regarded  as 
diseased,  the  patients  have,  at  first  at  least,  no  real  under- 
standing of  the  gravity  of  the  disorder.  Many  patients 
complain  bitterly  about  the  treatment  which  has  been 
accorded  to  them ;  an  extremely  stuporous  patient  who  for 
a  full  year  had  sat  huddled  up  in  bed,  whose  sensitiveness  to 
pin-pricks  had  been  tested,  and  whom  one  had  often  tried  to 
put  in  a  lying  position,  was  enraged  after  sudden  awaking 
from  the  stupor  because  she  had  been  thrown  into  bed  and 
that  iron  bars  had  been  bored  into  her  head.  Another 
demanded  30,000  marks  damages.  To  all  representations  of 
the  incomprehensibility  and  morbidity  of  their  conduct  the 
patients  give  as  answer  explanations  which  say  nothing,  they 
had  just  not  known  where  they  were,  were  without  cause  torn 
away  from  their  domesticity,  had  been  treated  in  quite  the 
wrong  way  ;  it  was  then  not  to  be  wondered  at,  if  they  had 
become  somewhat  confused. 

Recollection  of  the  period  of  the  disease  appears  as  a 
rule  to  be  fairly  clear,  but  very  imperfect.  The  patients  state 
that  it  may  well  be  possible  that  this  or  that  has  happened  so, 
but  they  did  not  know  about  it,  neither  could  they  explain 
how  they  had  behaved  as  they  did.  Sometimes  they  dispute 
some  of  the  occurrences  very  resolutely;  then  again  assert 
that  they  have  been  dead,  have  been  overpowered.  The 
intermingling  of  delusions  and  hallucinations  on  the  one 
hand,  the  inaccessibility  and  lack  of  insight  of  the  patients  on 
the  other  hand,  make  it  often  difficult  to  obtain  a  reliable 
account  of  the  real  substance  of  their  recollections.  The 
indifference,  however,  with  which  the  patients  regard  their 
own  serious  malady  is  almost  always  very  striking.  They 
do  not  feel  any  real  need  to  explain  to  themselves  the  details 
of  their  morbid  experiences,  do  not  ask  about  the  subject, 


152  DEMENTIA    PR/ECOX 

will  not  listen  to  anything  about  it,  smile  incredulously  when 
they  arc  told  about  it,  do  not -attribute  any  very  grave  import 
to  the  disorder ;  regard  themselves  at  once  as  perfectly  well, 
as  soon  as  they  have  become  to  a  certain  degree  clear  and 
quiet,  insist  without  more  ado  on  discharge,  blind  to  better 
counsel. 

Mood  in  states  of  stupor  usually  shows  no  marked  colour- 
ing. Often  the  patients  appear  to  be  in  a  state  of  anxious 
tension,  so  that  formerly  a  section  of  these  cases  was  named 
"melancholia  attonita,"  as  the  rigidity  was  connected  with 
emotions  of  anxiety  and  fearfulness.  It  is  as  a  rule  easy  to 
convince  oneself  that  fear  is  not  the  motive  of  the  patients' 
behaviour.  They  are  not  influenced  by  threats,  do  not  draw 
back  from  the  clenched  fist  or  the  drawn  knife,  do  not  blink 
when  the  point  of  a  needle  is  brought  near  their  eye.  Only 
in  the  beginning  of  the  disease  do  we  occasionally  notice, 
corresponding  to  the  depressive  delusions,  outbreaks  of 
violent  fear  and  despair.  Later  the  mood  changes  often 
without  recognizable  cause ;  pitiful  weeping  gives  place  to 
furious  irritation  or  childish  merriment,  while  a  dull  indiffer- 
ence forms  the  basis,  and  is  expressed  particularly  in  the 
behaviour  of  the  patients  to  their  nearest  relatives  and  in  the 
gradual  disappearance  of  wish  and  will. 

The  General  Course  of  the  catatonic  forms  is  very  varied 
as  already  appears  from  the  description  given.  It  shapes 
itself  in  still  more  changing  forms  because  in  about  one-third 
of  the  cases  considerable  improvement  in  all  morbid 
phenomena,  sometimes  re.sembling  complete  recovery  or 
coming  very  near  it,  occurs,  most  frequently  as  it  seems  in 
*  the  cases  beginning  with  a  state  of  depression.  The  duration 
of  these  periods  of  improvement  varies  greatly ;  they  most 
frequently  last  about  two  to  three  years  ;  but  they  sometimes 
last  nine,  ten,  twelve,  thirteen,  fourteen,  sixteen  years  ;  indeed 
once  between  the  first  attack  of  the  disease  and  the  second 
which  led  to  dementia,  there  was  an  interval  of  twenty-nine 
years.  The  objection  can  certainly  always  be  made,  that  in 
the  case  of  such  long  intervals  the  two  attacks  have  nothing 
at  all  to  do  with  each  other.  Meanwhile  the  observation  that 
a  pause  of  ten  years'  duration  between  two  attacks  with  quite 
similar  morbid  phenomena  is  frequent  in  this  as  in  other 
forms  of  dementia  praecox,  shows  there  cannot  well  be  any 
doubt  here  about  a  long  respite  and  renewed  outbreak  of 
the  same  morbid  process.  But  then  also  we  often  enough 
see  the  insidious  development  of  the  malady  extended  over 
long,  long  years  till  at  last  an  acute  disorder  announces  the 
real  outbreak  of  the  disease.      Not  altogether  seldom  the 


CLINICAL   FORMS  153 

disease  runs  its  course  in  three,  or  still  more,  attacks  separated 
by  periods  of  improvement,  attacks  which  in  certain  circum- 
stances may  at  first  be  of  only  quite  short  duration  before 
a  more  serious  one  commences  leading  to  dementia.  The 
individual  catatonic  states  may  either  follow  the  one  immedi- 
ately after  the  other  and  alternate  quickly,  or  be  separated 
from  each  other  by  long  intervals.  I  observed  a  case  where 
a  state  of  excitement  followed  the  introductory  stupor  only 
after  fifteen  years  ;  in  other  cases  the  malady  began  with  a 
state  of  stupor  which  was  first  interrupted  by  a  remission 
of  many  years  and  then  a  characteristic  state  of  excitement 
developed.  In  another  case  stupor  appeared  only  after  the 
malady  had  lasted  for  fifteen  years. 

In  the  terminal  states  dementia  along  with  the  phenomena 
of  negativism  and  mannerisms  was  in  great  excess.  Simple 
weak-mindedness  was  the  issue  in  about  1 1  per  cent,  of  the 
cases,  dull  dementia  still  somewhat  more  rarely.  Seizures 
were  observed  in  17  per  cent,  of  the  cases.  A  female  patient, 
thirty-one  years  of  age,  broke  down  completely  a  few  days 
after  an  attack  with  deep  unconsciousness  and  unilateral 
manifestations  of  cerebral  irritation.  On  the  whole  we  must 
reckon  the  catatonic  forms  with  the  more  unfavourable 
varieties  of  dementia  pra.^cox  on  account  of  the  frequency 
of  profound  dementia,  while  passing  improvements  are  some- 
what more  frequent  than  in  the  average  of  the  cases  here 
taken  into  account.  The  share  of  the  men  with  54  per  cent, 
and  of  the  cases  under  the  age  of  twenty-five  with  57  per 
cent,  does  not  deviate  from  the  average ;  still  the  forms 
beginning  with  stupor  seem  to  me  to  begin  at  a  somewhat 
more  advanced  age.  The  number  of  the  observed  cases 
included  19.5  per  cent,  of  the  whole  series. 

The  Paranoid  Dementias. 

A  picture,  which  is  in  many  respects  divergent,  is 
exhibited  by  those  cases,  the  essential  morbid  symptoms  of 
which  are  delusions  and  hallucinations  ;  we  call  them  paranoid 
forms.^  I  feel  justified  in  including  them  in  th.e  domain  of 
dementia  praecox  by  the  circumstance  that  in  them,  sooner 
or  later,  a  series  of  disorders  of  a  kind  which  we' everywhere 
find  also  in  the  other  forms  of  dementia  praecox,  invariably 
accompanies  the  delusions.  Further  in  a  large  number  of 
cases  .  terminal  states  are  developed,  which  completely 
resemble  the  forms  described  up  to  now,  and  also  in  the 
remaining   cases   a   psychic  decline   is   developed,  which   in 

^  Ferrarini,  Rivista  sperimentale  di  freniatria  xxx.  876  ;  xxxi.  435. 


154  DEMENTIA   PR.ECOX 

spite  of  many  peculiar  features,  nevertheless  discloses  a  near 
relationship  with  the  issues  of  dementia  praecox  already 
known  to  us. 

Paranoid  Dementia  Gravis. 

If,  as  seems  conformable  to  our  purpose,  we  let  ourselves 
be  guided  in  the  grouping  in  detail  by  the  point  of  view  of 
prognosis,  we  shall  next  have  to  take  into  consideration  those 
paranoid  morbid  states,  which,  it  is  true,  begin  with  simple 
delusions,  in  the  further  course,  however,  exhibit  always  more 
distinctly  the  peculiar  disintegration  of  the  psychic  life,  and  in 
especial  also  the  emotional  and  volitional  disorders  in  the  form 
characteristic  of  dementia  praecox  ;  they  might  be  grouped 
together  under  the  name  of  "  dementia  paranoides  gravis." 

The  development  of  the  disease  took  place  in  6^  per 
cent,  of  my  cases  insidiously  ;  in  17  per  cent,  of  the  patients 
there  existed  from  youth  upwards  certain  unfavourable 
peculiarities  of  character,  frivolity,  love  of  pleasure,  defiance, 
self-will,  unyielding  and  hasty  conduct.  Among  the  women 
there  were  several  prostitutes ;  among  the  men  fp  per  cent, 
were  vagrants.  In  about  30  per  cent,  of  the  cases  the  disease 
began  subacutely  ;  usually  it  was  a  case  of  convicts,  who  fell 
ill  during  imprisonment;  in  7  per  cent,  of  the  cases  the 
beginning  appeared  to  be  acute.  The  introductory  disorders 
are  quite  similar  to  those  of  the  remaining  forms  of  dementia 
praecox,  headaches,  tiredness,  aversion  from  work,  sleepless- 
ness, restlessness,  irritability,  a  changed,  monosyllabic,  shy 
behaviour. 

Delusions. — Gradually  there  come  "  forebodings,"  "  things 
come  to  light."  The  patient  notices  that  he  is  being 
oppressed,  too  little  considered,  he  is  being  maligned, 
insulted,  scoffed  at.  The  people  in  the  street  stop,  make 
jokes  about  him,  look  at  him  in  a  rude  way,  laugh,  make 
insinuations  as  if  he  had  stolen,  as  if  he  were  to  blame  for 
everything.  Everywhere  there  are  aiders  and  abettors  ;  a 
marriage  which  he  has  planned  is  being  prevented ;  the 
neighbours  are  taking  everything  out  of  the  house,  he  is 
being  plundered  and  robbed  ;  secret  debts  are  being  made, 
there  are  people  in  the  warehouse,  burglars  are  breaking 
in  ;  people  are  forcing  their  way  into  his  room.  The  Jews 
are  lying  in  wait  for  the  patient's  children  ;  his  relatives 
want  his  money  ;  the  parsons  spoil  everything ;  the  sermon 
is  aimed  at  him.  Newspapers  scribble  about  him  ;  letters 
are  changed  and  falsified  ;  everywhere  there  are  rascally 
tricks  and  Freemason  ongoings. 


CLINICAL   FORMS  155 

Everything  seems  changed  and  uncanny  to  the  patient. 
His  children  are  all  confused  ;  his  whole  surroundings  are 
bewitched  and  enchanted.  The  physicians  are  not  right 
physicians,  his  fellow-patients  are  suspicious  personages ; 
the  clock  stops  ;  money  has  not  the  security  that  it  once 
had.  Every  one  is  being  murdered  ;  everywhere  wounded 
men  are  seen  ;  his  father  and  brothers  and  sisters  are  being 
strangled,  roasted ;  the  Grand  Duke  is  being  killed  ;  the 
patient  is  in  a  den  of  murderers.  A  female  patient  thought 
that  outside  there  was  the  Lake  of  Constance,  and  it  had 
destroyed  all  countries  and  human  beings  ;  a  patient  said 
that  all  souls  were  lost ;  in  three  days  there  would  be  the 
last  judgment.  The  patient  acquires  the  conviction  that 
he  has  very  powerful  enemies  and  is  threatened  with  frightful 
dangers.  People  want  to  behead  him,  to  immure  him  in  the 
stove,  to  crush  him,  to  burn  him,  to  throw  him  to  wild 
animals  ;  sparrows,  rats,  dogs  with  goats'  hoofs  are  called 
out  against  him.  By  the  order  of  the  Grand  Duke  revolvers 
were  distributed  in  the  village,  he  is  going  to  be  brought 
before  a  secret  military  tribunal,  is  being  treated  as  a  political 
prisoner ;  a  patient  perceived  that  some  one  was  working 
at  her  coffin.  There  is  poison  in  the  beer,  soap  in  the 
drinking-water,  morphia,  hydrochloric  acid,  iodine  in  the 
food  ;  the  patient  accordingly  feels  burning  in  his  mouth 
and  obstruction  ;  everywhere  "  bellephonpoison  "  and  phos- 
phorus are  displayed  ;  the  dishes  are  dirty ;  bread  is  baked 
specially  for  him  by  the  baker.  His  enemies,  who  lie  in 
wait  for  him,  are  sometimes  Freemasons,  parsons,  the 
**  Frankfurter,"  the  devil,  "  Brother  Markus,"  sometimes  the 
nearest  relatives,  his  sister  and  especially  his  wife,  who  speaks 
evil  of  him  and  poisons  him  ;  he  feels  it.  She  takes  sides 
with  her  brother,  with  the  clergyman. 

Hallucinations  usually  appear  very  soon.  The  patients 
see  figures,  people  with  little  red  caps,  black  men,  cows, 
Christ,  angels  and  saints  at  the  altar,  "  little  figures  and  little 
souls,"  God,  the  Virgin  Mary.  A  patient  saw  a  man  in  green 
bathing-drawers,  who  was  playing  with  his  penis ;  a  female 
patient  saw  her  supposed  loved  one  lying  on  her  bed  at 
night.  By  far  the  most  frequent  are  auditory  hallucinations, 
whispering,  signals  from  the  air,  exclamations,  abusive  names. 
Voices  are  heard  in  the  sound  of  the  bell,  in  the  chirping  of 
the  birds,  in  the  sounds  which  animals  make ;  people  speak 
about  the  patient  and  his  wife ;  there  is  whispering  and 
ringing  in  the  walls ;  at  night  there  is  loud  talking  in  the 
room.  Sometimes  the  voices  seem  to  have  completely  the 
character  of  real  perceptions ;  the  patient  can  give  their  sub- 


156  DEMENTIA    PRECOX 

stance  in  words  and  also  recognize  their  supposed  authoi. 
Thousands  of  people  threaten  and  abuse  him  from  the  wall, 
said  a  patient ;  another  stated  that  he  had  got  his  hearing 
from  his  father  and  mother ;  a  third  said  when  he  was 
brought  to  the  hospital,  "  The  devils  of  fellows  speak  here 
too!" 

In  other  cases  the  illusions  are  more  or  less  sharply  dis- 
tinguished from  sense-impressions.  The  patient  hears  the 
voice  of  God,  invisible  beings  speak,  evil  spirits  let  him  have 
no  rest,  grossly  abuse  him  :  he  hears  all  sorts  of  things  "  in 
thoughts,"  has  voices  for  the  whole  of  Europe  by  the  appar- 
atus or  current ;  "  Nature  speaks  to  me,"  said  a  patient.  The 
voices  are  referred  to  different  places.  "  There  is  something 
in  my  ears,"  declared  a  patient ;  another  heard  "  memorial  " 
all  day  long  in  her  head.  *'  The  words  have  come  out  of  my 
stomach,"  asserted  a  male  patient,  while  a  female  patient 
heard  speaking  in  her  genitals,  and  another  thought  she  had 
a  telephone  in  her  feet. 

What  the  voices  say  is  usually  unpleasant ;  "  If  I  could 
only  get  rid  of  my  hearing ! "  exclaimed  a  patient  on  this 
account.  The  patient  hears  everything  that  one  says  or 
thinks  about  him,  that  he  is  going  to  be  executed,  beheaded, 
that  he  has  committed  lese-majeste  ;  "  He  is  to  be  got  rid  of," 
it  is  said  ;  there  is  a  war  going  on.  A  patient  heard  "  a  mur- 
muring," that  his  brother  was  dead.  Female  patients  hear 
"immoral  stuff","  sexual  accusations;  forest-whore,  married 
man's  whore,  strolling  whore;  they  have  committed  abortion, 
killed  a  child.  Sometimes  the  voices  forbid  the  patients  to 
work.     A  patient  heard  that  he  was  God. 

Frequently  the  patients'  own  thoughts  are  perceived  by 
others.  The  people  know  by  the  voice-telegraph  what  the 
patient  is  thinking ;  they  speak  of  his  thoughts  ;  what  he 
thinks  and  reads  is  repeated  after  him.  The  patient  answers 
silently,  speaks  with  the  voices  the  whole  day,  converses  with 
Kaiser  Wilhelm,  with  spirits,  carries  on  dialogues  "  on  the 
thought-way  through  the  nostrils."  Sometimes  also  the 
thoughts  are  made ;  the  patients  must  think  what  others 
think ;  transference  of  thought  takes  place ;  "  These  are 
things,  they  flow  to  one,  and  one  says  them,"  said  a  patient. 

Occasionally  also  other  kinds  of  hallucinations  come  under 
observation,  the  smell  of  corpses,  the  taste  .of  sulphur  in  the 
food,  mephitic  air,  the  feeling  of  being  electrified,  pulled  at, 
of  being  doubled.  "  Something  wanders  about  in  a  wonder- 
ful way  in  my  body,"  said  a  patient ;  another  felt  a  machine 
in  her  teeth  and  in  her  breast ;  the  taking  of  the  temperature 
caused  another  one  pains.     A  patient  had  pain  in-  his  heart 


CLINICAL  FORMS  157 

when  the  post  drove  by ;  another  complained,  "  The  cover 
smells  so  loud  "  ;  a  third  felt  "  chinks  of  pain." 

Hypochondriacal  Ideas. — In  the  further  course  of  the 
disease  the  delusions  soon  acquire  an  always  more  wonderful 
character.  In  especial  there  are  nonsensical  hypochondriacal 
ideas,  in  which  the  delusion  of  persecution  finds  shape,  pos- 
sibly in  connection  with  morbid  common  sensation.  Often 
also  the  delusions  are  connected  with  the  experiences  of 
dreams,  which  are  without  hesitation  regarded  as  reality. 
Blood  is  drawn  off  from  the  patient,  it  is  beaten  to  milk  ; 
something  is  taken  out  of  his  body,  his  bowels  are  torn  out ; 
everything  is  sawn  to  pieces,  his  face  is  disfigured,  his  heart 
is  stolen,  something  is  being  poured  into  his  throat.  A 
patient  thought  that  he  was  being  continually  filled  with 
water,  which  he  must  then  pass,  and  in  consequence  kept 
running  innumerable  times  to  the  water-closet.  His  eyes  are 
sprinkled  with  poison,  drawn  out  of  his  head  ;  his  sight  is 
taken  from  him  ;  "  something  is  being  done  to  my  fine  eyes," 
complained  a  female  patient.  His  head  is  closed,  pressed 
together,  is  to  be  made  confused  ;  the  skull-cap  is  being 
taken  off,  the  central  nerve  is  lacerated  and  bleeding,  the 
nervous  system  is  torn  down,  the  brain  is  bored  through  with 
Rontgen  rays,  the  head-power  is  weakened  ;  another  head 
has  been  put  on.  The  patient  is  to  be  made  crazy,  giddy ; 
his  understanding  is  stolen,  his  thoughts  are  criminally  taken 
from  him,  his  four  senses  are  fetched  away  by  the  doctor ;  he 
is  becoming  idiotic,  a  simpleton  ;  a  patient  complained  that 
he  could  not  stand  the  things  going  through  his  brain.  The 
patient  feels  that  he  must  die ;  his  blood  runs  cold,  his  inside 
is  annihilated  ;  beauty  is  gone,  the  freshness  of  life  is  lost. 
Something  is  wanting  in  his  head  and  spinal  marrow;  the 
brain  is  shrinking  ;  the  patient-  has  no  longer  any  intellectual 
life,  any  heart ;  he  must  live  for  ever. 

Sexual  Influences  usually  play  a  large  part  in  these 
complaints,  especially  in  female  patients.  At  night  women 
come ;  the  patients  feel  themselves  used  sexually  from 
behind  ;  their  nature  is  driven  off,  thrown  in  their  faces. 
Women  are  tormented  by  "  seductive  stories,"  violated  at 
night,  turned  into  whores ;  people  wish  to  practise  obscenity 
with  them.  The  physician  has  given  them  desire  in  their  bath  ; 
they  feel  it  sometimes  in  their  back,  sometimes  in  their  head, 
sometimes  in  their  hands.  At  night  there  are  seventeen  or 
eighteen  gentlemen  in  their  bed  ;  the  hospital  is  a  brothel ;  a 
female  patient  declared  that  the  obscene  practices  with  the 
three  and  four  must  now  cease.  The  abdomen  has  no  resist- 
ance, is  not   right,  the  periods   are  hindered ;   the  motherly 


158  DEMENTIA    PR.ECOX 

feelings  have  been  torn  out,  the  maternal  parts  have  been 
turned  outside  ;  the  patients  feel  themselves  "  made  nature- 
less."  The  womb  has  never  been  loved,  is  rotting,  sways 
about  in  the  hinder  parts  ;  the  ovary  is  to  be  operated  on, 
pepper  is  to  be  put  into  the  mouth  of  the  uterus. 

The  idea  of  being  infliie^tced,  constrained,  appears  distinctly, 
as  in  the  delusions  quoted,  also  in  many  other  utterances. 
The  patients  are  tormented  and  have  their  lives  threatened 
by  machines,  by  "  light-tube-ray-apparatus,"  by  sympathy, 
hypnotism,  enchantment  and  witchcraft.  They  are  influenced 
by  artificial  means,  are  changed  every  day,  feel  it  in  their 
body;  at  night  abductions  take  place.  A  power  drives  the 
patient,  accumulates,  goes  right  through  people,  gives  a 
ringing  tone  and  overcomes  him  ;  a  patient  was  caused  by 
the  compulsion,  by  the  "  going  round  of  his  head,"  to  go  twice 
to  America.  The  patient  feels  intrigues,  "mental  transferences 
to  planet  and  sun  "  ;  sentiments  all  run  to  him  ;  "intellectual 
patterns  are  being  fitted  on."  He  is  caused  to  have  pains  in 
his  back  ;  he  is  being  made  to  scratch  his  face.  Sometimes 
it  is  the  evil  eye  that  brings  this  to  pass  ;  the  physicians  speak 
the  eye-language ;  "  But  one  may  not  with  a  look  tear  out 
ninety  years  of  a  lifetime,"  complained  a  female  patient.  "  I 
am  a  depressed  body,  a  fettered  human  being,"  said  a  patient ; 
"lightning  things  have  no  aim";  another  pleaded  that  he 
would  like  to  have  his  rights,  his  power  again.  A  third  felt 
himself  in  "  public,  hypnotic  custody  "  in  spite  of  apparent 
freedom  in  the  enlarged  cage,  as  the  "  hypnotists  "  had  him 
completely  under  their  control  by  the  hypnotic  power  of 
their  eyes. 

Exaltation. — Alongside  of  the  ideas  of  persecution  there 
are  present  in  more  than  half  of  the  cases  exalted  ideas  ; 
in  a  small  number  of  cases  they  alone  dominate  the  clinical 
picture.  Usually  they  appear  only  after  some  time,  even 
after  several  years,  more  rarely  towards  the  beginning 
of  the  malady  ;  thus  in  the  case  of  a  postman  almost  the 
first  striking  morbid  symptom  was  that  he  signed  himself 
on  an  official  document  as  General  Field  Marshal.  The 
patient  has  supernatural  gifts,  has  made  important  inventions, 
the  Rontgen  apparatus,  the  "Peter  mobile";  he  possesses 
numerous  patents,  a  factory  ;  the  hospital,  the  country,  all 
kingdoms  belong  to  him.  He  has  money  in  the  safe,  has 
great  riches,  is  getting  a  situation  with  a  salary  of  lOOO 
marks ;  he  has  a  claim  to  thirty-two  millions,  which  have  been 
deposited  for  him  by  Rothschild  and  the  Shah  of  Persia ; 
he  demands  every  day  looo  marks  damages,  he  understands 
the  making  of  money;  a  patient  asserted  that  he  had  "the 


CLINICAL   FORMS  159 

ransom  "  as  he  twisted  off  all  the  buttons  from  his  suit  and 
attributed  to  each  the  value  of  some  thousand  marks.  The 
patient  is  prince  by  the  grace  of  God,  heir  as  German 
Emperor,  owner  of  the  German  Empire  ;  ,his  father  is  prince, 
Kaiser ;  he  was  at  the  age  of  twenty  -  five  king,  having 
inherited  from  his  great-grandfather  ;  he  possesses  a  privileged 
and  triumphal  canopy,  wants  a  uniform,  wants  to  live  in  the 
Castle,  wishes  to  have  an  explanation  from  the  local  magis- 
tracy about  his  lineage.  A  patient  who  was  hoarse,  thought 
that  he  had  the  Emperor  Frederick's  disease  and  was  there- 
fore related  to  him  and  of  royal  blood.  Another  is  rightful 
successor  of  the  cross  as  Pharaoh,  thought-reader,  clairvoyant, 
called  of  God,  born  for  the  salvation  of  all  mankind,  Paul, 
God  the  Father,  guardian  angel,  judge  of  the  quick  and  the 
dead.  He  has  two  natures,  a  divine  and  a  spiritual,  is  stand- 
ing already  in  the  red  magnificat,  must  punish  the  wicked, 
protect  the  pipus  ;  he  receives  revelations,  can  make  the 
sun  rise.  Many  patients  tell  a  story  of  inner  transformations 
which  they  have  experienced  and  in  which  their  future  high 
calling  has  become  clear  to  them  ;  a  vagrant  heard  then  that 
he  was  to  become  an  organ-builder.  A  patient  asserted  that 
his  fiancee  had  born  him  spiritually. 

Female  patients  are  Baroness  Bergshausen,  Planga  Geyer 
von  Geyersberg,  Countess  Drossel,  Empress  of  Ladenburg, 
royalties,  daughter  of  Kaiser  William  I.,  wife  of  the  Kaiser, 
must  take  the  place  of  the  Kaiserin  ;  they  get  maintenance 
from  the  Kaiser ;  they  are  ruler  of  the  world,  queen  of 
heaven,  lord  over  all  higher  things,  wish  to  redeem  mankind, 
have  the  keys  of  hell.  To  them  belong  all  kingdoms  ;  God 
is  their  dear  papa.  They  speak  of  their  subjects,  explain 
that  the  institution  belongs  to  them,  desire  to  go  to  a  grand 
hotel,  to  their  kingdom,  to  Berlin.  A  patient  declared  that 
she  was  Christ;  another  called  herself  by  her  husband's 
name,  asserted  that  he  was  her  wife,  asked  for  trousers  and 
wished  to  go  out  to  work  on  the  fields.  Many  patients  do 
not  acknowledge  their  husbands  any  more,  wish  to  marry 
a  baron,  travel  after  a  curate,  whom  they  think  is  their 
husband,  ask  the  physician  to  marry  them.  A  patient  put 
on  mourning  for  her  supposed  lover;  another  fell  in  love 
with  the  priest,  wished  to  go  with  him  to  Rome,  where  he 
was  to  become  pope  ;  a  third  declared  that  the  Kaiser  came 
to  her  every  night. 

Memory. — Here  and  there  the  delusions  are  connected 
with  errors  of  memory,  which  misrepresent  to  the  patients 
experiences  of  a  time  long  foro^otten,  back  in  their  earliest 
youth,  indeed  from  a  former  existence.     The  patients  think 


i6o  DEMENTIA   PRECOX 

that  they  are  supposititious  children  because  they  do  not 
resemble  their  brothers  and  sisters  ;  they  remember  being 
dandled  as  children  on  the  knees  of  the  reigning  prince  in  a 
beautiful  castle ;  later  they  were  badly  treated  by  their 
"  foster  parents,"  and  heard  all  sorts  of  hints  from  them 
that  had  reference  to  their  high  lineage.  A  patient  asserted 
that  he  had  already  lived  in  the  house  of  his  grandparents 
when  his  parents  married,  and  he  remembered  the  celebra- 
tion of  their  marriage ;  another  stated  that  he  had  lived 
in  America  from  1795  to  1820;  a  third  narrated  that  he 
was  born  in  1797  and  then  he  grew  up  in  Moscow  ;  he  was 
present  at  the  crucifixion  of  Christ,  had  founded  Universities, 
built  castles,  erected  the  Houses  of  Parliament,  hunted  lions 
in  Africa,  taken  part  in  all  campaigns.  These  cases  in  which, 
according  to  the  utterances  of  the  patients,  the  delusion  has 
apparently  already  begun  in  early  childhood,  gave  Sander 
the  occasion  for  the  description  of  an  "idiopathic"  paranoia, 
in  which  the  development  of  the  disease  was  said  to  extend 
back  into  childhood.  Further  experience  has  meanwhile 
shown  that  in  such  narrations  it  is  without  exception  a  case 
of  subsequent  morbid  invention.  Neisser  has  therefore 
frankly  put  down  as  the  characteristic  mark  of  the  group 
circumscribed  by  Sander,  errors  of  memory  and  proposed 
the  delimitation  of  a  "confabulating  paranoia."  According 
to  my  conviction  the  cases  of  Sander  which  have  been 
quoted  belong  to  dementia  praecox.  As  a  rule  the  errors  of 
memory  here  form  only  a  passing  morbid  symptom,  .so  that 
they  are  scarcely  suitable  for  the  delimitation  of  another 
group. 

If  at  the  beginning  it  is  in  some  measure  possible  to 
follow  the  patients'  train  of  thought,  in  the  further  develop- 
ment of  the  disease  the  senselessness  and  the  singularity  of 
the  mode  of  expression,  which  have  already  frequently 
appeared  in  the  examples  quoted,  become  so  pronounced 
that  it  is  scarcely,  or  no  longer  at  all,  possible  to  make  out 
the  meaning  of  the  morbid  utterances  ;  neologisms  also  help 
to  make  it  more  difficult.  The  patients  complain  about  the 
people  who  carry  on  murder,  the  subterranean  business  of 
human  beings  about  their  body  ;  at  night  they  feel  themselves 
drawn  out  through  a  needle.  The  bleaching-book  is  being 
opened  ;  the  railway  has  for  nine  years  closed  the  convict- 
prison  ;  intellect  was  brought  into  high  heaven ;  a  dog's 
trick  is  being  carried  on  with  them  ;  the  central  nerve  is 
being  led  off  from  its  origin.  They  have  growth,  the  murmur- 
ing of  the  sea,  no  more  breast-food,  liver-constriction,  white 
dysenteric  consumption  ;  an  acceleration  course  is  arranged 


CLINICAL   FORMS  i6i 

against  them.  A  patient  said  that  he  was  "the  abusive 
epithet  empire,  his  heart  certainly  and  human  life";  a  female 
patient  declared  that  she  bore  the  globe  and  the  telephone. 

In  spite  of  these  often  quite  incomprehensible  utterances, 
the  patients  are  usually  permanently  clear  about  their 
residence,  about  time  and  about  people,  even  though 
delusional  falsifications  and  wrong  interpretations  are 
frequently  recognizable.  Thus  a  patient  thought  that  she 
was  in  the  confusion-institution  ;  another  called  the  hospital 
the  casemate-convict  prison.  The  patients  also  often  mistake 
the  physicians  and  their  fellow-patients  and  they  disown 
their  own  relatives,  but  not  on  account  of  real  disorders  of 
perception,  but  in  connection  with  delusions.  Consciousness, 
apart  from  passing  states  of  excitement,  is  not  clouded;  the 
patients  are  sensible  and  perceive  fairly  well,  are  able  to  give 
an  account  of  their  circumstances,  and  to  solve  the  more 
simple  intellectual  exercises,  so  far  as  they  are  not  hindered 
in  doing  so  by  volitional  disorders  or  by  increasing  dementia. 
Of  understanding  of  the  disease  on  the  other  hand  there  is 
no  question.  The  patients  at  most  admit  that  through  the 
persecutions  they  have  become  somewhat  "  nervous."  "  To 
mention  in  one  word  myself  and  the  madhouse  is  just 
exactly  a  quadratic  perversity,"  wrote  a  patient.  Nor  does 
ocular  evidence  convince  the  patients.  If  they  are  taken  to 
the  room  where  they  suppose  that  the  persecutors  are,  they 
only  acknowledge  that  everything  suspicious  has  meantime 
been  cleared  away. 

Mood  shows  no  very  pronounced  colouring.  Many 
patients  exhibit  greatly  increased  self-consciousness  or  silly 
merriment ;  frequently  one  sees  them  breaking  out  into  cause- 
less  laughter?  Utliers  appear  remarkably  mditierent  and 
Unconcerned.  But  very  frequentTy  there  is  repellent,  irritable, 
quarrelsome  behaviour  with  occasional  violent  outbursts  ol_ 

*abuse,  and  even  acts  of  violence,  especially  at  the  time  of  the 
menses.  Sometimes  a  state  of  very  lively  sexual  excitement 
appears,  which  expresses  itself  in  regardless  masturbation, 
obscene  talk,  coarse  proposals  and  assaults.  A  female 
patient  continually  begged  in  the  most  urgent  way  to  be 
examined  with  the  metroscope  ;  another  stuffed  horsehair 
into  her  vagina. 

The  Activities  of  the  patients  seem  to  have  some  relation 
to  their  delusions  but  they  usually  bear  the  stamp  of 
singularity  and  incomprehensibility.  The  ideas  of  persecu- 
tion  lead  to  violent  outbursts  oi  rage  and  dangerous  attacks 

""on  fHe  supposeH  enemies.  1\  patient  threatened  the 
clergyman  that  he  would  shoot  him ;  another  locked  in  his 

L 


i62  DEMENTIA    PR/ECOX 

wife  and  children  and  handed  over  the  key  to  the  public 
prosecutor  for  further  enquiry.  A  female  patient  wished  to 
cut  her  father's  throat,  another  suffocated  her  friend,  a  third 
wished  to  kill  herself  and  her  child  because  she  had  heard 
"perdition  take  her  and  her  brood!";  a  fourth  hit  her 
husband  on  his  head  with  an  axe  "in  order  to  redeem  him." 
The  motives  of  these  attacks  are  often  very  obscure.  A 
patient  telt  himself  suddenly  lorced  to  injure  his  sisier  with 
whom  he  was  on  good  terms,  went  up  to  her  on  the  road  and 
stabbed  her  in  the  back.  Not  infrequently  the  patients  apply 
to  the  authorities  to  complain  about  the  persecutions  and  to 
ask  for  help,  sometimes  in  wholly  confused  documents.  The 
hallucinations  cause  the  patients  to  stop  their  ears  or  to  beat 
their  ears  ;  two  of  my  patients  in  this  way  brought  on  them- 
selves haimatomata  auris.  Others  speak  away  to  themselves, 
answer  the  voices,  call  into  the  heating  apparatus,  become 
restless  at  night  in  order  to  defend  themselves  from 
reproaches  and  abusive  language.  Ideas  of  poisoning  may 
lead  to  refusal  of  food  ;  a  female  patient  for  a  considerable 
time  only  ate  eggs  ;  one  patient  only  drank  milk  ;  another 
spat  a  great  deal  in  order  to  get  rid  of  the  poison  again. 
Many  patients  suddenly  fling  their  food  away,  because  it 
appears  suspicious  to  them.  A  patient  tied  herself  up  wholly 
in  cloths  in  order  to  protect  herself  from  the  influences  which 
she  feared.  Occasionally  it  comes  also  to  attempts  at 
suicide ;  a  patient  tried  to  remove  his  testicles  by  ligature  ; 
a  female  patient  swallowed  needles. 

Exalted  ideas  connected  with  religion  lead  to  the  declaim- 
ing of  texts  from  the  Bible,  to  preaching  and  fasting,  to 
abuse  of  the  clergy  ;  a  patient  built  for  himself  a  house  altar. 
Here  also  the  taking  of  food  is  often  involved.  A  female 
patient  took  only  bread  and  water ;  a  patient  fasted  on 
Thursday  and  Friday ;  another  thought  that  a  higher  being 
did  not  require  to  eat  at  all,  nor  to  ease  himself.  A  female 
patient  went  to  the  local  medical  officer  and  asked  him  to 
cut  open  her  back  and  fix  in  angels'  wings.  Sexual  excite- 
ment causes  the  patients  to  commit  dissolute  acts,  to  decide 
to  be  divorced,  to  make  an  attempt  to  approach  any  wholly 
unknown  person  whatever  of  the  opposite  sex,  and  to  commit 
immoral  acts  on  children.  A  female  patient  wished  to  marry 
her  brother. 

Alongside  of  these  volitional  expressions,  which  after  all 
are  still  to  a  certain  exttent  comprehensible,  go  others  for 
which  intelligible  motives  can  scarcely  be  discovered.  The 
patients  wander  through  the  house  at  night ;  they  suddenly 
stoj)  the  alarum   clock,  tear  out  stakes   from   the  vineyard, 


CLINICAL   FORMS  163 

tear  down  the  vines,  search  in  the  graveyard  for  the  grave 
of  their  wife  who  is  still  alive,  run  to  the  water-closet  a 
hundred  times  in  the  day,  cut  off  their  hair.  Sometimes  here 
also  delusions  may  play  a  part  to  which  the  patients  do  not 
give  expression  ;  but  often  we  have  certainly  to  do  with 
purely  impulsive  actions,  about  the  origin  of  which  the 
patients  themselves  are  not  able  to  give  any  exact  account. 
This  view  appears  certain  in  the  numerous  actions  which  we 
have  come  across  in  quite  similar  form  in  the  types  of 
dementia  praicox  previously  discussed  and  which  we  have 
there  learned  to  recognize  as  the  result  of  the  volitional 
disorders  peculiar  to  this  disease. 

Negativism. — Next  we  meet  with  a  series  of  negativistic 
phenomena.  The  patients  are  repellent,  inaccessible,  mono- 
syllabjc,  even  mute,  withdraw  themselves,  hide  themselves 
away,  draw  the  clrover  over  their  hea3.  One  patient  gave 
utterance  to  his  thoughts  only  in  writing ;  others  only  answer 
in  indefinite  phrases  or  speak  past  the  subject.  They  do  not 
shake  hands  because  they  "  do  not  need  to,"  "  may  not  do  it," 
because  they  "  do  not  any  longer  go  in  for  frivolity."  Or 
they  give  the  left  hand,  the  finger-tips,  or  wrap  up  their  hand 
in  their  handkerchief  Many  patients  keep  their  eyes  closed, 
cover  their  mouth  with  their  hand,  lie  down  in  other  people's 
beds,  refuse  food  at  times  without  recognizable  cause,  now 
and  then  pass  their  excreta  under  them ;  if  told  to  employ 
themselves,  they  refuse.  On  the  other  hand  the  patients 
occasionally  again  exhibit  automatic  obedience,  are  cataleptic, 
put  out  their  tongue  non-voluntarily  to  be  pierced  through, 
imitate  what  is  called  out  to  them  or  done  in  front  of  them. 
Often *they  are  seen  assuming  singular  attitudes,  standing 
the  whole  day  on  one  spot,  staring  in  front  of  them. 

Mannerisms  are  often  a  marked  feature.  The  patients 
pull  faces,  stick  out  their  lips  like  a  snout,  suck  their  fingers, 
make  peculiar  gestures,  which  sometimes  appear  to  represent 
a  kind  of  sign- language,  move  affectedly,  adorn  themselves 
tastelessly,  put  their  bedclothes  together  in  a  singular 
manner,  let  down  their  hair,  spit,  click  their  tongue,  cut  their 
words  when  they  speak,  speak  rhythmically,  in  affected  High 
German,  in  a  Frenchified  style.  Among  these  are  inter- 
polated all  kinds  of  senseless  impulsive  actions.  The  patients 
pull  out  the  hair  of  their  beard,  turn  about  their  own  axis, 
suddenly  climb  right  up  the  window,  smash  panes  of  glass, 
throw  the  dishes  about  the  room,  f/ Stereotypies,  pulling  at 
their  fingers,  rocking  movements,  runnmg  round  m  circles, 
'mbnotonous  'movements  of  arm  and  hand,  rhyming,  verbi- 
geration are  also  frequent. 


i64  DEMENTIA    PRECOX 

Speech. — The  substance  of  expression  in  speech  is 
incoherent,  odd,  exhibits  drivelling  verbosity,  a  tendency  to 
sounding  phrases,  quotations,  silly  plays  on  words,  neologisms, 
sometimes  going  on  to  complete  confusion.  The  whole 
manner  of  speech  of  the  patients  becomes  in  this  way, 
especially  in  the  later  periods  of  the  disease,  extremely 
peculiar,  and  bristles  with  bewildering  turns  of  expression. 
A  female  patient  described  herself  as  being  ill-treated  "churl- 
wise,"  "  horrorwise,"  "  pretensionwise,"  and  as  being  an 
"embezzled  mama";  a  patient  called  himself  the  "artificially 
opposed  person  " ;  another  asserted  that  the  physicians  were 
"  reversed  doctors."  "  Live  without  liver  has  been  telegraphed 
to  me,"  said  a  patient ;  a  second  said  "  When  one  gives  any 
one  the  hand,  one  is  love"  ;  a  third  received  me  with  the 
words,  "I  believe  that  the  gentlemen  are  there  for  my 
confidence  and  not  for  yours."  "  Doctorship  is  being  made 
with  me,"  complained  a  female  patient,  while  another  on 
being  asked  about  hallucinations,  replied :  "  The  attache 
affair  has  been  finished  for  two  years."  Again  another 
expressed  herself,  "  Personal  right  does  belong  to  me,  a  man 
who  steps  in  for  me;  the  avertor  must  avert,"  and  a  patient 
dismissed  me  with  the  words,  "  Are  you  a  state  model  ? 
Radius,  radius,  that's  enough."  Complete  agrammatism, 
inability  to  form  grammatical  sentences,  also  occurs  ;  a 
patient  replied  to  me  when  I  spoke  to  him  :  "  Sleeping  and 
dreaming  and  emotional  state  without  sympathy  and  without 
master-key."  In  the  patients'  writings  similar  oddities  again 
occur :  at  the  same  time  we  often  meet  here  a  singular 
arrangement  of  lines  and  letters  and  queer  orthogj;aphy. 
These  disorders  of  the  expression  of  speech  in  word  and 
writing  agree  perfectly  with  those  which  we  have  an 
opportunity  of  watching  in  the  terminal  stages  of  other 
forms  of  dementia  prsecox. 

Course. — In  another  direction  also  the  issues  of  this  group 
correspond  completely  with  those  of  the  clinical  types 
hitherto  discussed.  As  terminal  state  the  most  frequent 
is  manneristic  dementia,  somewhat  seldomer  negativistic  or 
drivelling  dementia.  Only  in  about  12  per  cent,  of  the  cases 
simple  weak-mindedness  is  developed  without  other  more 
.striking  morbid  residua  ;  just  as  often  dull  dementia  sets  in. 
I  could  not  verify  any  essential  improvements  with  later 
relapse  among  my  cases,  which  embrace  rather  more  than 
9  per  cent,  of  all  the  cases  of  dementia  pr.xcox  ;  there  were 
seizures  in  only  3  per  cent,  of  the  patients.  The  form  here 
described  belongs  accordingly  to  the  less  favourable  varieties, 
Its  course  is  essentially  more  chronic  and  more  monotonous 


CLINICAL   FORMS  165 

than  any  we  have  hitherto  seen  ;  remissions  of  the  morbid 
phenomena,  as  well  as  seizures  which  may  well  be  interpreted 
as  specially  violent  expressions  of  the  disease,  disappear 
almost  completely.  The  fact  is  very  remarkable,  that  here 
the  male  sex  with  44  per  cent,  remains  considerably  below 
the  average,  but  especially  that  only  26  per  cent,  of  our 
patients  were  below  twenty-five  years  of  age.  This  paranoid 
form  is  therefore  by  preference  a  disease  of  middle  and  later 
life ;  a  few  cases  occurred  in  the  sixth  decade  of  life.  We 
call  to  mind  here  that  depressive  dementia  with  delusions, 
which  shows  many  points  of  contact  with  this  form,  also 
shows  a  certain  preference  for  riper  years.  If  progressive 
experience  confirms  our  present  assumption,  that  in  all  the 
clinical  pictures  here  separated  from  one  another,  it  is  still 
a  case  of  the  same  morbid  process,  one  might  suppose  that 
with  more  advanced  age  in  itself,  the  tendency  to  more  pro- 
nounced delusions  grows,  while  at  the  same  time  the  possi- 
bility of  a  more  complete  disappearance  of  the  disorders 
decreases  and  the  course  becomes  more  gradual.  That 
delusional  forms  of  disease  usually  belong  in  general  more 
to  riper  age  is  confirmed  by  many  experiences.  Also  in 
paralysis  we  see  that  the  forms,  which  occur  in  youth, 
generate  delusions  with  considerably  less  frequency. 

Paranoid  Dementia  Mitis. 

As  a  further  form  of  paranoid  dementia  praecox  I  think 
that  I  should  now  add  another  group  of  cases,  which  on  the 
one  hand  exhibit  a  quite  similar  development  and  the  same 
delusions  as  the  paranoid  diseases  just  described,  but  on  the 
other  hand  result  in  peculiar  states  of  weak-mindedness. 
While  there  in  the  terminal  states  principally  the  volitional 
disorders  and  the  incoherence  of  the  original  clinical  picture 
remain  behind,  here  we  have  to  do  with  the  development  of 
a  psychic  decline  which  is  specially  characterized  by  the 
continuance  of  delusions  or  hallucinations  ;  the  issue  of  the 
malady  is  a  state  which  we  may  c^.\\  paranoid  or  hallucinatory 
weak-mindedness.  As  here  the  substance  of  the  personality 
seems  to  be  less  seriously  damaged,  it  is  perhaps  allowable 
to  speak  of  a  "  dementia  paranoides  mitis." 

The  beginning  of  the  disease  was  in  74  per  cent,  of  my 
cases  slowly  progressive,  while  about  9  per  cent,  set  in 
acutely,  the  rest  subacutely.  But  certainly  also  in  these 
last  cases  slighter  changes  had  frequently  for  a  considerable 
time  preceded  the  actual  onset.  Almost  always  indeed  it  was 
a  case  here  of  the  outbreak  of  morbid   phenomena  during 


i66  DEMENTIA    PRECOX 

imprisonment  in  individuals  who  already  years  ago  had  fallen 
into  a  career  of  crime,  sometimes  after  good  development  in 
the  beginning,  but  often  also  on  the  foundation  of  a  disposi- 
tion unfavourable  from  the  first  or  a  neglected  education.  In 
20  per  cent,  of  the  cases  the  patients  had  shown  mediocre  or 
poor  endowment  at  school  ;  some  were  described  as  from 
youth  up  stubborn,  self-willed,  wicked,  suspicious,  peculiar, 
"  nervous.'"  Among  the  men  two-thirds  were  vagrants  and 
criminals,  probably  a  sign  that  we  had  here  to  do  either  with 
individuals  of  inferior  disposition,  or,  what  for  many  cases 
seemed  to  be  the  more  correct  view,  with  a  very  gradual 
change  which  reached  far  back  into  the  past  and  which  only 
after  a  considerable  number  of  years  acquired  marked  morbid 
features.  In  all  these  directions,  therefore,  the  form  here 
treated  behaves  quite  like  the  other. 

Hallucinations  and  Ideas  of  Persecution. — The  first 
manifestations  of  the  disease  also  seem  to  be  the  same,  as  far 
as  they  can  at  all  be  verified  in  the  usually  very  slow  develop- 
ment. The  patients  become  suspicious,  irritable,  insubordin- 
ate, at  times  threatening  and  violent,  behave  in  a  conspicuous 
way,  carry  on  singular  conversations,  often  change  their  situa- 
tions, stop  working.  Little  by  little  it  then  becomes  clear 
that  they  are  suffering  from  hallucinations,  generally  auditory, 
and  from  ideas  of  persecution.  In  the  cases  which  set  in 
acutely,  especially  during  imprisonment,  these  disorders  are 
usually  the  first  striking  morbid  symptoms. 

The  substance  of  the  hallucinations  is  mostly  hostile, 
provocative.  In  the  beginning  there  is  perhaps  only  a  buzz- 
ing, ringing,  humming  ;  but  then  the  patient  hears  how  he  is 
mocked  and  abused  by  his  neighbour ;  he  is  called  bastard, 
rogue,  dirty  dog,  prison  thief,  wild  swine,  shabby  beast,  young 
swine  ;  they  are  "  voices  of  persecution."  Frequently  im- 
moral things  are  said.  The  patient  hears  indecent  talk  about 
himself;  he  is  said  to  have  assaulted  his  children  criminally ; 
"  bigamy  "  is  called  out.  Women  are  abused  as  "  princes' 
prostitute,  rose  prostitute,  princes'  drabs  "  ;  a  patient  heard 
ladies'  voices  which  called  out  to  him  that  he  was  to  come  and 
love  them  ;  another  was  called  "  pencil-sharpener  "  (onanist) 
More  rarely  it  says,  "  He's  a  pretty  boy,  a  handsome  fellow.' 
Sometimes  everything  that  the  patient  does  is  discussed  : 
"  every  now  and  then  he  peeps  again."  The  master  of  the 
house  telegraphs  what  he  says ;  the  voices  hear  everything 
know  his  thoughts,  say  them  aloud  beforehand,  repeat  aloud 
what  he  reads;  there  is  thought-reading,  double  speech.  A 
patient  thought  that  two  people  saw  through  his  ej'es  every- 
thing that  happened. 


CLINICAL   FORMS  167 

But  he  also  can  read  the  thoughts  of  others,  feels  what 
people  intend  to  do  with  him.  The  voices  are  sometimes 
quite  transcendental,  "  secret  voices,"  "  inward  voices," 
"  thought  brooding,"  inspirations  from  above,  sometimes 
whispering,  "whispering  to  him,"  "inblowings,"  "murmuring." 
People  speak  through  air-shafts,  from  the  clock  or  through  a 
phonograph,  sing  into  his  ears ;  people  over  him  and  above 
him  speak  ("  Roof-runners,"  "  Behind-wallers  ") ;  from  all  sides 
there  is  telephoning  ;  the  patient  "  is  in  touch  with  everyone  " ; 
someone  is  sitting  in  his  left  ear.  Now  and  then  it  is  God  or 
Christ  who  speaks.  The  voices  often  control  the  patient 
continuously,  especially  in  the  night,  the  attendants  have  him 
at  night  on  his  trial ;  it  is  a  "  nightly  cross-examination." 

Visual  hallucinations  are  more  rare.  The  patient  is  being 
dazzled  and  reflected  ;  he  sees  a  shining  light  in  the  room, 
bright  squares,  lines,  pictures  of  saints  in  the  sky,  a  cross 
and  the  Saviour,  the  ascension  of  Jesus  in  the  firmament ; 
"  That  does  not  happen  to  everyone,"  added  a  patient. 
Others  see  "  pictures  produced  as  if  for  entertainment,"  black 
figures  ;  a  patient  asserted  that  he  saw  everything  through 
glasses  in  the  wall.  With  these  are  associated  putrid  smells, 
a  "colossal  smell  of  phosphorus,"  stinking  vapours,  bitterness 
in  mouth  and  nose,  the  taste  of  petroleum,  bugs,  chloride  of 
lime,  human  faeces,  sulphur,  oil,  spirit,  onion  juice,  white-lead, 
pepper,  poison  of  all  kinds  in  his  food ;  he  feels  sick  after 
taking  the  milk  ;  the  beer  is  blood-water. 

Dysaesthesiae. — If  it  is  already  in  such  utterances  of  the 
patients  often  difficult  to  decide,  whether  it  has  to  do  with 
real  hallucinations  or  not,  it  is  in  still  higher  degree  the 
case  in  the  manifold  dysaesthesiae  of  which  they  habitually 
complain.  They  have  stitches  in  the  lung,  feel  themselves 
"embraced  by  cold,"  have  a  sensation  of  burning  and  stirring 
in  their  stomach,  cold  in  their  lung,  oppression  in  their  heart. 
There  is  pricking,  punching  and  cutting.  The  skin  itches,  is 
too  narrow  ;  their  hinder  parts  are  gone  so  that  they  cannot 
sit ;  they  cannot  take  a  deep  breath,  have  no  longer  any 
lungs  ;  their  brain  is  running  to  pieces ;  filth  is  running  out 
at  their  ears.  Very  soon  these  sensations  are  connected  with 
external  influences  and  insanely  worked  up.  The  patient  is 
worried  day  and  night,  tormented,  burnt,  made  filthy,  ruined 
in  his  health  ;  he  is  tortured  in  every  part  of  his  body.  His 
blood  is  drawn  from  his  nose  and  body  ;  saliva  is  squirted 
into  his  face  and  mouth ;  he  is  infected  with  diphtheria ;  he 
is  given  an  enema  "  of  churchyard  putrefaction,"  dangerous 
medicines  are  introduced  into  him  by  little  tubes,  pulverized 
sublimate  is  put  in  his  eye  ;  his  ears  and  head  are  blown  up  ;  he 


i6S  DEMENTIA    PR^ECOX 

is  burnt  with  machines  ;  he  is  shot  in  the  ears  with  5000  small 
shot,  electric  shocks  are  |,nven  to  him ;  a  hundred  mice  run 
over  his  back.  His  flesh  is  torn  off,  taken  from  his  shoulders 
with  a  magnet ;  he  is  "  damaged  "  ;  his  heart  is  sewed  up,  his 
throat  pressed  together  ;  the  urinal  is  fixed  in  ;  his  throat  is 
made  raw  ;  his  face  old.  His  foot  is  being  cut  up,  his  buttocks 
torn  ;  his  veins  are  being  laid  hold  of  and  cut  through,  his 
teeth  are  being  destroyed.  Children  are  boring  round  about 
his  buttocks  ;  his  bowels  are  being  "  wound  up  and  deposited 
in  plates"  ;  fieces  are  pumped  up  into  his  brain;  his  "sex  is 
drawn  out  horizontally  and  put  in  again  vertically."  There 
is  a  magnet  in  his  ear,  wheelwork  in  his  breast,  that  moves 
him  like  a  jointed  doll.  The  clergyman  has  pressed  out  his 
brain  by  the  nose;  the  patient  is  "filled  up  and  filled  in," 
must  breathe  in  mice  and  cats  ;  alternating  currents  come 
undulating  towards  him  ;  there  is  a  "  current-war."  Often 
these  torments  are  given  special  names;  "filthy  murder"  is 
being  practised,  "  urine  magic "  is  being  carried  on ;  the 
patients  speak  of  twitching  of  the  fingers,  swelling  of  the  flesh, 
.stanching  of  blood  and  letting  blood  flow,  event-making, 
bomb-bursting,  lobster-cracking,  and  so  on.  A  patient  wrote 
that  in  him  "  hallucinizations,  alienations,  exstirpations,  in- 
formations, transversalism,  orthotroph)',  and  so  on "  were 
being  aimed  at. 

Besides  the  extraordinary  forms  of  the  dyssesthesicX,  the 
circumstance  that  the  tortures  are  often  referred  to  the  time 
of  sleep,  is  also  favourable  to  the  interpretation  that  every- 
where here  it  is  a  case  more  of  delusions  than  of  erroneous 
perception.  The  bed  is  moving  ;  the  patient  is  tormented  at 
night  by  blows  in  the  ribs  and  electrification ;  in  sleep  his 
breast  is  pressed  in,  or  his  bones  are  taken  out  of  him  and 
replaced  by  sticks.  At  night  "spiritual  underselling"  takes 
place;  there  is  "  much  coming  and  going";  "at  night  one 
does  not  have  night  rest,"  said  a  patient.  Here  it  may  some- 
times be  a  case  of  the  interpretation  of  dreams  as  the  patients 
frequently  without  any  hesitation  transfer  dream  experiences 
to  reality. 

Varied  Persecutions- — All  other  possible  ideas  of 
persecution  also  make  their  appearance.  The  patient  is  being 
made  a  fool  of,  everywhere  announced  already  beforehand, 
watched  and  persecuted  by  policemen,  tempted  by  Satan,  is 
lost,  infected,  outlawed,  is  to  be  ruined,  condemned  to  death, 
shot,  chloroformed,  strangled,  got  rid  of,  executed,  must  die  in 
May,  will  be  buried  in  an  unconsecrated  churchyard.  He  is 
being  cheated,  robbed  ;  people  force  their  way  in  with  false 
keys,  spoil  his  food  for  him  ;  holes  are  being  bored  in  the 


CLINICAL   FORMS  169 

roof;  cart-grease,  chloride  of  lime,  soap  is  being  thrown  down. 
Letters  are  falsified,  suppressed  ;  lottery-tickets  disappear ; 
political  intrigues  are  taking  place ;  justice  is  being 
administered.  The  clergyman  preaches  false  doctrine;  in 
the  newspaper  there  are  allusions  ;  "  people  understand  it 
already,"  said  a  patient.  The  questions  addressed  to  him  are 
'•puzzles";  the  people  round  him  are  females,  "masked"; 
a  conspiracy  exists  in  which  the  accomplices  relieve  each 
other.  There  are  uncanny  ongoings  in  the  house,  like  a  plot, 
a  "  double  world  " ;  everything  is  enchanted  ;  even  the  cat 
is  instigated  to  breathe  on  the  patients.  His  wife  is  dead, 
estranged  by  witches'  sympathy,  killed  by  the  doctor  ;  his  son 
is  ripped  up,  hung,  his  daughter  burned ;  his  children  have  a 
knife  in  their  neck,  have  got  into  the  subterranean  regions  ; 
in  the  house  patients  are  being  slaughtered  and  worked  up 
into  sausages. 

Sexual  delusions  are  very  frequent.  The  patients  are 
jealous,  think  that  they  are  married  elsewhere;  the  children 
are  not  theirs  ;  a  female  patient  thought  that  her  husband  had 
fifty-four  wives  and  fifty-four  children.  The  patient's  wife  puts 
menstrual  blood  in  the  food  ;  a  female  who  can  make  herself 
invisible  persecutes  the  patient.  Immoral  plays  are  being 
represented  ;  figures  of  little  girls  appear  and  excite  the 
patient  sexually  ;  he  is  irritated  by  unchaste  talk.  Female 
patients  are  said  to  be  misused,  made  pregnant  by  magnetic- 
electrical  methods  ;  men  lie  in  wait  for  them  ;  at  night  filthy 
fellows  work  about  them  ;  there  is  match-making  going  on. 
Filthy  deeds  are  being  carried  out ;  the  penis  is  being  tickled, 
rubbed  off;  the  semen  poured  off,  nature  drawn  off.  A 
patient  was  invited  by  voices  to  associate  sexually  as  stallion 
with  the  daughters  in  better-class  families. 

Sometimes  Polish  Jews,  the  clergyman,  a  former  sweet- 
heart, the  secret  Fj-eemason  association,  the  neighbours,  the 
magicians  in  the  subterranean  vault,  the  sister-in-law,  the 
overseer  in  the  prison  are  regarded  as  the  originators  of  the 
persecutions ;  a  patient  thought  there  was  "  a  nightly, 
religious,  secret,  assassinatory,  governmental,  civil  war."  As 
means  used  by  their  persecutors  the  patients  suppose 
apparatus,  an  electric  death-dealing  current,  a  "  patent 
electrifying  apparatus,"  with  which  also  they  occasionally  see 
someone  occupying  himself,  300  machines  and  a  patented 
large  clockwork  which  moves  everything ;  "  with  electricity 
much  can  be  done "  ;  there  are  two  souls  who  electrify  the 
patient.  He  feels  himself  "  full  of  galvanization,"  is  being 
tormented  by  the  machine,  "  telegraphed  through,"  examined 
by  Rontgen  rays  ;  there  are  physical  experiments,  pestilential, 


I70  DEMENTIA    PRECOX 

or, it  is  enchantment,  witchcraft.  A  patient  thought  that  the 
passers-by  drew  blood  out  of  his  body  by  means  of  an 
instrument  like  a  cupping-glass  which  they  had  in  their 
mouths. 

Influence. — The  description  of  influence  on  thoughts  and 
on  volition  usually  play  a  special  part  also  jn  the  complaints 
of  these  patients.  "  Thronging  of  thoughts "  takes  place  ; 
the  "thought-examiner"  exercises  an  influence;  "the  apparatus 
causes  laughing,  crying,  cold,  trembling,  sensations  in  the 
body."  The  vehmgcricht  causes  tensions  ;  the  patient  feels 
himself"  forced  back,"  "confined,"  depressed,  "in  all  relations 
disturbed,"  he  is  "excommunicated  "  ;  it  comes  to  "criminal 
oppressions  and  inquisitions."  He  is  worked  on  by  thoughts; 
he  must  do  what  the  voices  command,  is  pressed  to  certain 
actions  by  suggestion.  His  body  is  like  a  machine  which  is 
made  to  speak  ;  his  tongue  is  guided  for  him  ;  "  They  loosen 
the  tongue  for  me,  and  one  must  speak,  whether  one  will  or 
not."  In  the  involuntary  making  of  a  mistake  in  writing 
a  word,  "  the  probability  of  inspiration  prevails."  The  spirits 
hinder  the  patient  at  work  ;  his  thoughts  are  taken  out  of  his 
head,  so  that  he  cannot  think  anything.  Or  thoughts  are 
given  to  him  which  are  not  his  own  ;  the  imputation  is  made 
to  him  as  if  he  imagined  himself  a  king.  Then  again  he  is 
stupefied,  hypnotized,  put  into  a  magnetic  sleep,  must  give 
information.  A  patient  was  instructed  to  pull  out  his  hair ; 
"  That  continues  working  till  I  do  it,"  he  explained.  States 
of  excitement,  flow  of  saliva  are  caused  in  the  patient  ;  he  is 
secretly  examined  medically  by  magnetic  influence,  made 
crazy ;  his  whole  understanding  is  being  destroyed.  With 
this  he  feels  rays  in  his  lips  ;  the  voices  penetrate  to  his 
bones.  A  patient  addressed  a  letter  to  us  "concerning 
spiritualistic  conditions,"  in  which  he  begged  for  our  medical 
help.     It  said  here: —  » 

"  The  above-mentioned  spiritualistic  conditions  of  my  person  consist 
in  a  real  speaking  with  souls  in  the  inside  of  my  head.  Their  thought- 
disturbing  influence  is  imposed  on  me  by  the  mystical-beings  mentioned, 
in  a  compulsory  way  by  boring  and  piercing,  continual  itching  in  my 
head  in  a  way  not  to  be  described.  I  call  this  ill-usage  by  souls 
compulsory,  as  a  man  cannot  ward  off  from  himself  their  contravening 
influences  in  the  inside  of  his  body.  This  disturbance  frequently  so 
severe  often  passes  into  a  state  in  which  a  man  does  not  know  at  all  any 
longer  what  he  is  doing.  It  appears  to  me  that  I  am  performing  an 
action  which  is  exactly  the  opposite  of  what  I  ought  to  do.  I  regret 
having  become  a  victim  of  a  spiritualistic  seizure.  Displeasure  shown 
not  to  wish  to  speak  with  souls  remains  ineffectual.  I  beg  to  be  allowed 
to  apply  with  confidence  to  the  hospital  in  order  to  be  able  to  hope  for 
final  relief  in  the  conditions  of  disturbed  soul." 


CLINICAL   FORMS  171 

Besides  the  auditory  and  sensory  illusions  the  painful 
constraint  of  the  patient  appears  here  clearly,  which  goes 
as  far  as  the  reversal  of  volitional  impulses,  further  the  feeling 
of  morbidity  and  of  the  need  for  help,  without,  however,  any 
clear  understanding  of  the  real  character  of  the  malady. 

Exaltation. — In  nearly  half  of  the  cases  there  are  also 
exalted  ideas,  sometimes  appearing  at  the  beginning,  some- 
times first  at  a  later  period.  The  patients  are  not  the 
children  of  their  parents,  they  are  of  noble  birth,  related  to 
the  Kaiser,  son  of  the  Emperor  Nikolas,  daughter  of  the 
Grand  Duchess,  of  the  King  of  the  Suabians,  "  put  in  the 
world  by  the  Grand  Duke  by  command  of  the  Kaiser,"  have 
a  claim  to  the  throne  of  Bavaria  ;  a  patient  asserted  that  he 
was  135  years  old  and  had  been  a  volunteer  with  a  red 
uniform  for  one  year  in  Russia.  Female  patients  are  a 
former  queen,  Countess  Salm,  Baroness  von  Lichtenstein. 
The  Emperor  Frederick  has  visited  them,  made  their  son 
minister;  the  Duke  of  Coburg  has  given  them  lottery-tickets; 
they  are  going  to  the  Grand  Duke  and  to  the  Kaiser  at 
Berlin,  and  are  waiting  for  the  carriage  which  is  to  fetch 
them.  Other  patients  have  got  an  inheritance  from  America, 
millions,  several  billions  are  deposited  for  them;  they  are 
supported  by  rich  people,  do  not  need  to  work  any  more  ; 
a  female  patient  thought  that  her  husband  had  renounced 
seven  millions  in  order  to  be  able  to  marry  her.  Others  again 
have  made  great  inventions,  built  the  dirigible  air-balloon, 
possess  currents  with  which  they  influence  other  people,  can 
see  into  the  sun,  know  what  will  happen  next  day,  are 
"  Dr  of  Industry,"  sinless.  A  patient  connected  a  dissolution 
of  the  Reichstag  with  a  letter  written  by  him  to  the  Emperor 
and  thought  he  found  an  allusion  in  the  words  of  the  Bible, 
"The  city  lieth  foursquare"  to  his  town,  Mannheim;  a  female 
patient  asserted  that  she  had  been  operated  on  and  had  got 
a  rectum  "of  silver  foam."  Secret  relations  to  persons  of 
the  other  sex  are  very  frequent.  The  patient  is  "thrown 
together"  with  highly-placed  persons  at  night,  hears  the 
voice  of  his  fiancee  who  invites  him  to  sexual  intercourse  ; 
the  Empress  is  presented  to  him  "  with  charming  speeches." 
Female  patients  recognize  in  some  man  or  other  their  dis- 
guised fiance,  to  whom  they  give  themselves  without 
hesitation,  and  whom  they  love  "  with  their  whole  heart " ; 
it  is  the  Baron  "Josa  von  Bolza."  They  were  married 
very  many  years  ago  to  Prince  William;  the  Prince  Regent 
will  bring  them  to  the  throne ;  the  physician  is  their  Prince 
Consort. 

Consciousness  seems  unclouded  during  the  whole  course 


172  DEMENTIA   PR^^COX 

of  the  disease.  So  far  as  delusions  do  not  come  into  account, 
the  patients  are  permanently  clear  about  their  place  of 
residence,  the  reckoning  of  time,  the  persons  in  their  sur- 
roundings and  their  situation  in  general. 

Mood  is  very  variously  coloured.  At  first  the  patients 
are  usually  depressed,  suspicious,  irritable,  quarrelsome,  at 
times  very  excited,  inclined  to  immoderate  outbursts  of  abuse 
and  even  to  deeds  of  violence ;  some  make  impulsive 
attempts  at  suicide,  throw  themselves  into  water,  or  out  at 
the  window.  Later  the  patients  become  as  a  rule  duller  and 
more  indifferent,  even  though  occasionally  they  may  still 
become  very  violent.  Many  patients  exhibit  a  cheerful,  self- 
conscious  mood,  make  all  sorts  of  jokes,  laugh  and  simper. 

^^^^     Onanism  isMiot  rare. 

r^^^H  The    Activities    of    the 

^^  ^^^1     patients  are  partly  influenced 

^^^  '^^^    by    their    delusions.      They 

complain  to  the  police  about 
the  persecutions,  bring  their 
complaint  before  the  court, 
write  innumerable  letters  to 
the  authorities,  compose  com- 
prehensive documents,  ask 
for  testimonials,  health  certi- 
i*'K;  31-  ficates;  a  woman  went  to  the 

stopper  for  nose  of  a  paranoid  patient.  .   .  j        .      i  . 

'^^  f  r  court  m  order  to  be  present 

at  her  trial  for  divorce  which  she  thought  was  taking  place 
there.  Other  patients  search  through  the  house  for  perse- 
cutors, stop  up  the  keyholes,  abruptly  leave  the  house  to 
wander  about  without  a  plan,  cease  working.  A  patient  asked 
the  supposed  father  of  his  child  to  pay  him  board,  and  locked 
his  wife  out  of  the  house.  A  woman  wanted  to  kill  her 
husband  and  children;  a  man  beat  his  wife  on  her  head  with 
a  hammer.  The  patients  try  to  protect  themselves  from  the 
voices  by  stopping  up  their  ears  ;  a  patient  had  a  stopper  for 
his  nose  made  with  fine  holes  for  breathing,  which  is  repro- 
duced in  Fig.  31,  in  order  in  this  way  to  prevent  the  injection 
of  saliva  and  the  drawing  out  of  blood. 

The  patients  try  to  keep  off  from  themselves  hostile 
poisoned  arrows  and  flashes  of  light  by  large  screens  and 
masks.  A  patient  surrounded  his  whole  bed  with  wires  on 
which  he  hung  up  in  great  number  phallic  amulets.  Merklin 
has  described  a  patient  who  for  his  protection  wore  armour 
made  of  old  metalware,  which  weighed  twelve  kilograms. 
Another  had  himself  limited  the  movements  of  his  arms  by 
a  leather-belt  with  loops  in  Order   to  be  able  to  resist  the 


CLINICAL   FORMS  173 

impulse  to  scratch  his  face,  an  impulse  which  was  caused  by 
his  enemies.  Many  patients  try  to  protect  themselves  from 
the  influences  by  peculiar  gestures,  defensive  movements, 
definite,  often  very  intricate,  attitudes,  low  continual  repetition 
of  certain  words.  Others  apply  to  the  public,  vent  their  anger 
by  means  of  advertisements  in  the  newspapers,  wall  posters, 
open  letters,  pamphlets,^  or  they  undertake  some  or  other 
very  conspicuous  course  of  action  in  order  to  attract  general 
attention  to  their  situation.  The  patients  often  hope  to  be 
able  to  withdraw  themselves  from  the  persecutions  by  frequent 
change  of  situation  and  dwelling-place.  A  patient  crossed 
the  French  frontier  in  order  to  see  if  the  currents  could  reach 
him  there  also;  when  he  had  convinced  himself  that  they 
could,  all  he  wished  for  further,  was  to  go  across  the  sea, 
although  on  account  of  the  cable  he  cherished  little  hope  of 
escaping  in  this  way  ;  should  this  means  also  fail,  he  was 
determined  to  kill  himself 

Conduct. — The  general  conduct  of  life  of  the  patients  is 
invariably  influenced  to  a  considerable  degree  by  their 
malady.  Many  are  impelled  to  enter  the  path  of  crime 
(theft,  indecent  assault)  or  vagrancy  ;  they  wander  restlessly 
about,  are  not  capable  of  any  regular  work,  neglect  themselves 
and  come  down  in  the  world.  Others  whose  lives  are  better 
protected,  can  keep  themselves,  it  is  true,  for  a  longer  time  in 
freedom  without  too  far  overstepping  the  bounds  of  decorum, 
but  still  show  some  or  other  of  the  peculiarities  which  are 
known  to  us  as  accompanying  phenomena  of  dementia  pra:;cox, 
catalepsy,  echolalia,  echopraxis,  frequent  negativism,  but 
above  everything  mannerisms  and  impulsive  actions. 

The  patients  are  often  inaccessible,  repellent,  mute,  refuse 
the  visits  of  their  nearest  relatives ;  "  that's  got  no  aim." 
They  answer  questions  with  counter-questions,  with  the 
remark  that  one  knows  already  everything  oneself,  curtly 
deny  all  morbid  phenomena,  do  not  enter  into  any  conversa- 
tion, do  not  associate  with  anyone,  hide  themselves  away 
under  the  cover,  refuse  food  or  at  least  special  kinds  of  food,  do 
not  shake  hands  ;  "  that's  of  no  use."  Other  patients  exhibit 
a  peculiar,  affected  behaviour,  kneel  the  whole  night  through, 
laugh  without  occasion,  spit  round  about  themselves,  have  a 
different  reckoning  of  time,  fast  on  Sunday  because  it  is 
Friday,  suddenly  cut  off  their  hair,  smash  panes  of  glass, 
throw  the  dishes  about  the  room.  Many  patients  are  restless 
at  night,  carry  on  loud  soliloquies,  use  violent  language  about 

^  WoUny,  tjber  Telepathic,  1888  ;  Sammlung  von  Aktenslucken,  1888 ; 
TefFer,  Uber  die  Tatsache  des  psycho-sexualen  Kontaktes  oder  die  actio  in 
Distans.  1891  ;  Schreber,  Denkwiirdigkeiten  eines  Nervenkranken,  1903. 


174  DEMENTIA   PRECOX 

the  persecutions,  sing   songs  because   it   occurs  to   them  to 
do  so. 

Conversation. — Very  commonly  the  conversation  of  the 
patients  bears  a  pecuHar  stamp.  The  manner  of  speech  is 
frequently  affected,  sought-out  High  German,  interspersed 
with  foreign  words,  unusual  turns  of  speech,  odd  expressions. 
Man\'  patients  are  very  loquacious,  and  in  a  longer  conversa- 
tion produce  a  veritable  throng  of  incomprehensible  and  un- 
connected utterances,  although  they  are  able  to  give  quite  clear 
and  reasonable  information  if  they  are  asked  definite  questions. 
Neologisms  play  a  great  part,  especially  in  the  description  of 
the  manifold  persecutions.  The  patients  are  "  ilisiert," 
"  tupiert,"  "desanimiert,"  "  anstimuliert,"  gone  to  sleep, 
weakened,  revenged,  jeered  at ;   "  impulse  is  placed  on  in- 


Specimen  of  writing  5.     Writing  of  a  paranoid  patient. 

stinct";  everything  is  placed  fullof'Isi,"  bepovvdered  with 
"  turmalin,"  the  house  is  "  verdreieidigt."  They  are  tormented 
by  "  Hineinzahmen,"  "  Befeinigen,"  by  "  Stigmatisie  and 
Hypnotisie,"  by  "  Introchieeii,"  "  Veneriepocken  "  ;  they  are 
in  an  "epileptic  Bengalese  convict-prison."  A  patient  spoke 
of  "steel-chip-pin-sausages"  and  called  his  persecutors 
"electric  assassin-homicide-rivercommissionbusiness-stinking 
he-goats.'' 

Writing. — The  documents  also  which  are  sometimes 
very  numerous  and  monotonous,  exhibit  in  their  singular 
flourishes  and  their  often  scarcely  intelligible  spelling  the 
most  remarkable  derailments  of  the  movements  of  expression. 
I  insert  here  two  specimens  of  writing  of  a  shoemaker, 
which  were  written  at  an  interval  of  seven  months.  He 
sought  out  in  the  newspaper  all  possible  expressions  from 
foreign  languages,  and  wove  them  in  with  a  meaning  invented 
by  himself  in  his  decree  as  "heavenly  physician,  astronomer 
and  President  Lichtenstern."  In  the  second  there  are  the 
words  "  Fidelis  Syphilis,"  which  he  explained  as,  "  Thus  shall 
it  happen."     The  change  in  the  character  of  the  writing  from 


CLINICAL   FORMS 


175 


pretentious   self-consciousness   to   stiff   eccentricity   is   very 
characteristic. 

In  the  Further  Course  of  the  disease  the  specially 
striking  disorders  very  gradually  disappear  to  a  certain 
extent.  The  patients  become  more  accessible,  quieter, 
complain  less  about  the  persecutions,  possibly  even  begin  to 
occupy  themselves,  though  they  may  perhaps  refuse  regular 
work,  because  they  are  not  paid,  or  are  not  obliged  to  work. 
Some  patients  become  quite  useful  and  eager  workers.  But 
along  with  that  the  hallucinations  and  delusions  continue,  with- 


Specimen  of  writing  6.    Writing  of  the  same  patient  seven  months  later. 


out  being  corrected  in  any  way ;  they  only  lose  more  and  more 
their  power  over  the  actions  of  the  patients.  We  may, 
therefore,  contrast  the  terminal  states  which  develop  here  as 
hallucinatory  or  paranoid  weak-mindedness  with  the  forms  of 
mental  decline  hitherto  characterized.  The  hallucinations 
persist  but  the  patient  "no  longer  pays  so  much  attention  to 
them,"  only  speaks  of  them  if  he  is  asked  explicitly  about 
them,  or  even  then  says  that  he  has  already  for  some  time 
heard  nothing  more,  the  last  time  was  a  few  days  ago.  He 
also  possibly  allows  that  he  has  been  ill,  that  it  was  a  case  of 
congestion,  of  nervousness,  but  yet  he  scarcely  ever  acquires 
a  clear  understanding  of  the  character  of  the  morbid 
phenomena.  Meanwhile  he  learns  to  come  to  terms  with 
them,  does  not  let  himself  be  influenced  by  them  any  more. 
A  patient  who  still  occasionally  heard  abusive  voices  while 
he  worked  outside  as  a  painter,  it  is  true,  asked  anyone  he 
met,  "  What  did  you  say?",  but  was  at  once  reassured  when 
he  was  told  that  no  one  was  speaking,  and  he  then  knew  that 


176 


DEMENTIA    PRECOX 


it  was  again  a  case  of  "  voices."  Often  the  voices  are  heard 
at  times  more  distinctly  and  still  control  the  patient  tempor- 
arily till  quietness  is  again  restored.  This  kind  of  patient 
occasionally  speaks  in  terms  of  the  most  violent  abuse,  but  is 

shortly  afterwards  completely 
accessible  and  up  to  a  certain 
point  intelligent.  Such  attacks 
occur  especially  at  night,  so 
that  the  patients  then  become 
very  disturbing  to  their  neigh- 
bours, while  during  the  day 
they  scarcely  show  any  devia- 
tion from  normal  conduct. 

In  about  20-25  per  cent,  of 
the  cases  temporary  or  per- 
manent hallucinations  without 
further  working  up  form  the 
only  striking  residuum  of  the 
disease  which  has  been  under- 
gone. In  the  remaining  cases 
there  are  still  preserved  a 
greater  or  less  number  of  delu- 
sions, the  significance  of  which, 
however,  in  the  psychic  life  of 
the  patients  gradually  disap- 
pears more  and  more.  They 
do  not  speak  much  about  them 
on  their  own  initiative  or  they 
mention  them  without  empha- 
sis like  other  indifferent  sub- 
jects and  do  not  become  excited 
about  them  any  more.  Many 
patients  still  hand  in  from  time  to  time  documents  with 
monotonous  repetition  of  their  former  complaints  and  claims, 
possibly  even  still  fall  into  excitement  if  one  investigates 
their  delusions,  but  accustom  themselves  to  some  or  other 
regular  employment.  While  the  expression  of  their  exalted 
ideas  can  still  be  recognized  in  their  peculiar  adornment, 
as  in  the  patient  pictured  in  Fig.  32,  they  yet  adapt 
themselves  in  other  matters  without  resistance  to  the  daily 
routine  of  institution  life.  The  "rex  totius  mundi "  occupies 
himself  with  work  in  the  garden,  the  "  Lord  God  "  with  carry- 
ing wood,  the  "  Bride  of  Chri.st "  with  sewing  and  darning. 
Of  course  this  change  always  goes  alongside  of  a  blunting  of 
the  emotions.  The  patients  have  become  more  indifferent ; 
the  circle  of  their  interests,  wishes,  hopes,  has  narrowed  itself 


Paranoid  patient  with  ornaments. 


CLINICAL   FORMS  177 

considerably ;  their  mental  activity  and  their  endeavour  are 
extinguished.  At  the  same  time  all  sorts  of  traces  of  the 
former  volitional  disorders  may  still  be  preserved,  singulari- 
ties in  behaviour  and  especially  in  speech. 

The  form  here  described  seems  to  be  just  about  as  frequent 
as  the  former.  Temporary  disappearance  of  all  morbid 
symptoms  might  occur  once  in  a  while  quite  exceptionally. 
Seizures  were  observed  in  5  per  cent,  of  the  cases.  Here  also 
accordingly  the  whole  history  of  the  disease  is  unfavourable  ; 
the  course  is  slowly  progressive.  To  the  male  sex  belonged 
53  per  cent,  of  my  patients,  a  proportion  that  possibly  is  ex- 
plained by  the  fact  that  in  Heidelberg  numerous  vagrants 
and  prisoners  from  the  neighbouring  convict  prisons  were 
admitted,  who  with  special  frequency  fall  ill  in  the  way 
indicated  here. 

Causes. — About  the  cause  of  this  remarkable  process 
only  hypotheses  can  be  made.  It  might  be  that  we  have 
here  to  do  with  a  form  which  develops  specially  slowly, 
and  which  for  many  years  before  the  onset  of  the  more 
striking  morbid  phenomena  brings  about  changes  in  the 
psychic  life,  such  as  must  lead  to  the  path  of  the  vagrant  and 
of  the  criminal.  For  this  view  the  fact  would  also  speak, 
that  apparently  only  12  per  cent,  of  our  patients  at  the 
beginning  of  the  malady  had  not  yet  passed  their  twenty-fifth 
year ;  perhaps  we  would  frequently  have  to  place  the  begin- 
ning of  the  morbid  change  much  earlier  than  usually  happens 
according  to  the  customary  view  of  it.  On  the  other  hand  it 
cannot  be  denied  that  clearly  the  influences  of  imprison- 
ment and  of  the  workhouse  are  specially  suited  to  produce 
paranoid  conditions.  We  may  therefore  look  at  it  somewhat 
in  this  way,  that  we  have  here  to  do  with  an  unusually  slow 
development  of  the  morbid  process,  which  makes  it  possible 
for  the  patient  for  a  long  time  still  to  continue  to  live  as  an 
apparently  healthy  individual,  while  yet  at  the  same  time  the 
increased  difficulty  in  the  struggle  for  existence,  which  results 
from  the  disorder,  and  the  unfavourable  influences  of  life 
favour  the  development  of  paranoid  trains  of  thought. 

CONFUSIONAL   SPEEgH   DEMENTIA. 

A  last  very  peculiar  group  of  cases,  the  discussion  of 
which  has  to  be  interpolated  here,  is  formed  by  the  patients 
with  confusion  of  speech.  These  are  cases  of  disease  the 
development  and  course  of  which  correspond  in  general  to 
those  of  dementia  praecox.  On  the  other  hand  the  issue  is 
divergent.     It  consists  in  a  terminal  state,  which  is  essentially 

M 


178  DKMKNTIA    PR/ECOX 

characterized  by  an  unusually  striking  disorder  of  expression 
in  speech  with  relatively  little  impairment  of  the  remaining 
psychic  activities.  If  one  will,  one  may  therefore,  relying  on 
Hlcuier's  nomenclature,  speak  of  a  "  schizophasia." 

Commencement. — Sometimes  a  gradual  failing  with 
restlessness  and  silly  actions,  sometimes  a  moody  condition 
with  irritating  hallucinations,  ideas  of  persecution  and 
serious  attempts  at  suicide  forms  the  beginning.  Often  the 
malady  is  developed  in  short  attacks,  between  which  there 
are  remissions  of  considerable  extent  and  lasting  for  years. 
Some  patients  sink  to  vagrants  ;  one  became  a  crier  at  market 
stalls.  But  by  degrees,  now  and  then  apparently  within  a 
fairly  short  time,  the  extremel)-  remarkable  morbid  symptom 
is  developed,  which  characterizes  these  patients  above  every- 
thing, confusion  of  speech. 

General  Features. — Perception  and  memory  usually 
show  no  considerable  disorder,  as  far  as  can  be  judged  from 
the  utterances  of  the  patients  ;  in  any  case  the  patients  are 
clear  about  their  place  of  abode,  also  about  time  relations, 
recognize  quite  correctly  the  people  in  their  surroundings, 
even  though  they  often  give  them  wonderful  names  to  which 
they  usually  adhere.  Auditory  hallucinations  appear  still  to 
persist,  but  play  no  recognizable  part  in  the  psychic  life  of 
the  patients  and  are  not  further  worked  up.  Indications  also 
of  delusions  appear,  ideas  of  persecution,  complaints  about 
influences  at  night,  "  interpolations,"  and  along  with  these 
there  are  exalted  ideas.  All  these  delusions  are,  however, 
extraordinarily  vague,  are  only  produced  occasionally  in  often 
changing,  often  half-jocular,  form,  and  acquire  no  influence 
over  the  rest  of  thought  and  activity.  The  patients  are 
mentally  active,  accessible,  show  interest  in  their  surroundings, 
often  also  follow  the  events  of  the  day  quite  well. 

Mood  is  invariably  exalted,  self-conscious,  at  times 
irritable,  usually  pleasant ;  the  patients  are  lively,  inclined  to 
jokes  and  to  little  harmless  tricks.  Conduct  and  outward 
behaviour  are  reasonable,  sometimes  a  little  affected,  submissive 
or  whimsical  ;  the  patients  have  the  tendency  to  adopt  all 
sorts  of  little  peculiarities  from  which  they  are  only  with 
difficulty  dissuaded.  At  the  same  time  they  are  as  a  rule 
very  useful,  diligent  and  clever  workers,  who  occupy 
themselves  without  assistance,  but  like  to  go  their  own  way, 
ward  off  every  interference  in  their  doings,  will  not  work  with 
others,  for  the  most  part  fulfil  their  obligations  with  great 
carefulness,  but  probably  also  once  in  a  while  do  something 
quite  nonsensical.  In  this  way  they  usually  fit  in  without 
difficultv  in  the  life  of  the  institution  and  make  for  themselves 


CLINICAL   FORMS  179 

there  a  modest  sphere  of  work,  without  giving  utterance  to 
more  ambitious  desires. 

Speech. — All  the  patients  show  a  certain  flow  of  talk 
which  certainly  only  expresses  .itself  in  conversation,  here 
and  there  perhaps  also  in  soliloquies.  As  .soon  as  they  are 
addressed,  they  frequently  answer  with  great  vivacity  and 
immediately  take  up  the  attitude  of  a  lecturer.  To  simple 
questions  put  with  emphasis  they  generally  give  a  short  and 
suitable  answer.  Or  perhaps  that  throng  of  disconnected 
utterances,  which  was  described  before,  begins  immediately, 
or  at  most  after  the  first  still  tolerably  intelligible  sentences. 
It  is  produced  in  flowing  speech  and  with  a  certain  satisfaction 
on  the  part  of  the  patient.  These  utterances  are  mostly  quite 
unintelligible  and  are  richly  interspersed  with  speech  derail- 
ments and  neologisms.  Often  the  current  can  only  be  brought 
to  a  standstill  by  the  interference  of  the  questioner  and 
can  again  be  immediately  put  in  motion  by  renewed  question- 
ing. Sometimes  it  is  possible  from  the  behaviour  of  the 
patient  and  from  detached,  less  nonsensical  parts  of  the  talk, 
to  make  at  least  very  vague  guesses  what  thoughts  he  wishes 
perhaps  to  express,  stories  of  long  ago,  complaints,  boasting, 
taunts,  but  all  hidden  in  the  most  bewildering  phrases  which 
abruptly  digress  into  the  most  remote  domains  of  thought. 

An  example  of  such  utterances  is  given  in  the  following 
letter : — 

"The  sentimental  vocation  of  tbe  Welschneureuther  citizens  re- 
<juires  above  everything  that  after  the  subhme  birthday  festival  of  his 
Majesty  the  illustrious  King  William  Charles,  all  his  spiritual  powers 
should  be  collected  in  order  to  do  justice  to  their  pastoral  intercession  in 
the  Lord.  So  forty  respected  stormpatriots  in  view  of  the  repeal  of  the 
statutes  of  the  University  of  Erlangen  have  to-day  taken  it  upon  them  to 
confirm  as  first  retrospective  negative  in  analogical-patriotic  sense.  To 
place  at  the  most  gracious  disposition  of  his  Majesty  the  Art.  i  of  the 
Welschneureuther  constitution,  consisting  in  combustible  available  war- 
material,  further  most  obediently  to  stop  the  most  notorious  dealings  as 
intercourse  with  cattle,  sheep  and  turkeys.  Now  in  order  that  the 
sublime  royal  company  cannot  be  subjected  to  any  competition  from  the 
neighbouring  states  in  transportable  tempers  all  to  be  recommended  to 
indulgence,  we  swear  by  the  profit  of  enhanced  merchandise  only  to 
serve  each  alone,  only  then  to  break  off  a  consequence  of  the  balance  of 
the  nineteenth  century  to  be  drawn  periodically  and  mechanically,  when 
we  shall  be  able  to  be  expectantly  deceived  in  our  opinions  toward*  our 
august  ruler  and  regarded  as  a  useful  adviser  of  a  healthy  antiquarian 
museum  and  so  on." 

On  the  whole  the  construction  of  the  sentences  here  is  to 
a  certain  degree  preserved  so  that  this  drivel  might  perchance 
make  the  impression  of  internal  connection,  if  it  were  read 
inattentively  or  by  anyone  who  had  imperfect  understanding 


i8o  DEMENTIA    PR/ECOX 

of  the  language.     On  more  exact  inspection  there  is  certainly 
no  longer  an>'  question  of  that. 

Peculiarity  of  this  Form. —  It  might  be  supposed  that  in 
the  form  of  disease  outlincd.it  was  only  a  case  of  drivelling 
dementia  of  a  specially  high  degree  ;  there  also  incoherent, 
confused  talk  with  neologisms  and  nonsensical  phrases  come 
to  the  front.  But  what  distinguishes  our  patients  here,  is  the 
sense  and  reasonableness  in  their  behaviour  and  in  their 
actions,  which  compels  us  to  the  assumption  that  this  is  a  case 
not  so  much  of  a  severe  disorder  of  thought  but  much  rather 
of  an  interruption  of  the  connections  between  train  of  thought 
and  expression  in  speech.  In  any  case  we  have  to  do  with 
an  unusual  restriction  of  the  volitional  disorder  to  a  narrowly 
limited  territory  of  volitional  activity,  that  of  expression  in 
speech,  in  which  it  at  the  same  time  reaches  a  quite  peculiar 
extent.  Perhaps  this  limitation  of  the  phenomena,  which  is 
certainly  not  quite  strict,  is  conditioned  by  a  special  site  of 
the  morbid  process  similar  to  what  we  have  seen  in  the 
atypical  paralysis,  still  the  possibility  should  probably  also 
not  be  left  out  of  account,  that  we  have  here  before  us  a 
peculiar  form  of  disease  which  is  indeed  related  to  dementia 
precox  but  is  yet  not  essentially  the  same. 

The  severity,  with  which  the  phenomenon  of  confusion  of 
speech  appears,  is  subjected  to  great  fluctuation.  Many 
patients  are  usually  able  to  express  themselves  at  first  quite 
intelligibly,  but  fall  into  their  nonsensical  talk  as  soon  as  one 
speaks  for  a  longer  time  with  them  or  when  they  become 
excited.  Further,  periods  are  frequently  noticed  which  recur 
with  approximate  periodicity,  in  which  the  patients  are  more 
ill-tempered  or  excited,  and  then  become  much  more  easily 
confused  in  speech  ;  it  is  exactly  this  peculiarit\-  which  com- 
pletely corresponds  with  the  observations  in  the  other  terminal 
states  of  dementia  prctcox.  But  lastly  a  state  of  confusion  of 
speech  may  again  disappear  even  after  existing  for  many 
years,  till  only  slight  traces  remain  noticeable  during  excite- 
ment. That,  for  example,  was  the  case  of  the  patient  from 
whom  the  letter  given  above  originated  ;  he  applied  later  in 
a  quite  correct  way  for  a  post.  At  the  same  time  there  is 
here  certainly  no  question  of  real  recovery.  Lack  of  insight 
into  their  morbid  state  and  lack  of  judgment,  restlessness  and 
aimlessness  in  work,  a  tendency  to  use  high-sounding  phrases, 
and  superficiality  of  the  emotions  remain  behind  even  ia 
favourable  cases. 


CHAPTER    VI. 
COURSE  AND   REMISSIONS. 

The  general  course  of  dementia  praecox  is  very  variable. 
On  the  one  hand  there  are  cases  which  very  slowly  and 
insidiously  bring  about  a  change  in  the  personality,  out- 
wardly not  specially  striking  but  nevertheless  very  profound. 
On  the  other  hand  the  malady  may  without  noticeable 
prodromata  suddenly  break  out,  and  already  within  a  few 
weeks  or  months  give  rise  to  a  serious  and  incurable  psychic 
decline.  In  the  majority  of  cases  with  a  distinctly  marked 
commencement  a  certain  terminal  state  with  unmistakable 
symptoms  of  weak-mindedness  is  usually  reached  at  latest 
in  the  course  of  about  two  to  three  years.  One  must  always 
be  prepared  for  acute  exacerbations  of  the  disease  leading 
to  a  lasting  aggravation  of  the  whole  condition.  Not 
altogether  infrequently  the  true  significance  of  a  change  in 
the  personality  lasting  for  decades  is  first  cleared  up,  by  the 
unexpected  appearance  of  more  violent  morbid  phenomena, 
in  the  sense  of  dementia  precox. 

The  fact  is  of  great  significance  that  the  course  of  the 
disease,  as  we  have  seen,  is  frequently  interrupted  by  more 
or  less  complete  remissions  of  the  morbid  phenomena  ;  the 
duration  of  these  may  amount  to  a  few  days  or  weeks,  but 
also  to  years  and  even  decades,  and  then  give  way  to  a 
fresh  exacerbation  with  terminal  dementia.  Evensen  saw  a 
patient  have  a  relapse  after  thirty-three  years.  Pfersdorff^ 
established  improvement  for  the  duration  of  two  to  ten  years 
twenty-three  times  in  one  hundred  and  fifty  cases  (15  per 
cent.) ;  I  myself  found  real  improvement  in  26  per  cent,  of 
my  cases,  when  that  of  the  duration  of  a  few  months  was 
also  taken  into  account.  It  has  been  already  mentioned 
that  such  improvement  is  to  be  expected  most  frequently 
in  the  forms  which  begin  with  excitement,  and  is  almost 
entirely  absent  in  paranoid  forms  of  the  disease  as  also  in 
simple  silly  dementia;  one  is  reminded  here  of  similar 
experiences  in  paralysis,  in  which  the  expansive  forms  also 
exhibit  frequent  and  considerable  improvement  while 
demented  paralysis  rarely  does  and,  if  it  does,  the  improve- 

^  Pfersdorff,  Zeitschr,  f.  klinische  Medizin  Iv.  1904. 


iS2  DEMENTIA   PR/ECOX 

ment  is  only  sliijht.  Amonij  women  improvement  seems  ta 
be  rather  more  frequent  than  among  men. 

The  Beginning  of  the  improvement  takes  place  as  a  rule 
very  graduallw  The  excited  patients  become  quiet;  the 
stuporous  more  accessible  and  less  constrained  ;  delusions 
and  hallucinations  become  less  vivid  ;  the  need  for  occupa- 
tion and  for  the  taking  up  again  of  former  relationships 
becomes  active.  At  the  same  time  sleep,  appetite,  and 
bod}--\veight  usuall)-  improve  considerably.  But  astonishing 
improvement  may  appear  quite  suddenly  ;  it  then  for  the 
most  part  certainly  does  not  last  long.  We  find  the  patient, 
who  up  till  then  appeared  to  be  quite  confused  in  his  aimless 
activit}-  or  his  hopeless  degradation,  all  at  once  quiet  and 
reasonable  in  every  way.  He  knows  time  and  place  and  the 
people  round  about  him,  remembers  all  that  has  happened, 
even  his  own  nonsensical  actions,  admits  that  he  is  ill,  writes 
a  connected  and  sensible  letter  to  his  relatives.  It  is  true 
that  a  certain  constraint  of  manner,  a  peculiarly  exalted  or 
embarrassed  mood  and  a  lack  of  a  reall\'  clear  understanding 
of  the  morbid  phenomena  as  a  whole  will  always  be  found 
on  more  accurate  examination. 

The  Degree  of  improvement  reached  is  very  different  in 
individual  cases.  Among  those  here  worked  up  by  myself 
there  were  127  patients  who  ultimately  became  demented, 
in  whom  such  a  degree  of  improvement  occurred,  that  a 
return  to  home  life  was  possible  ;  in  eight  further  cases  which 
exhibited  a  periodic  course,  such  improvement  occurred  even 
very  frequently.  In  these  latter  cases,  however,  there  existed 
in  the  intervals  a  distinct  psychic  weakness  gradually 
increasing,  which  for  the  most  part  bore  the  stamp  of  simple 
emotional  dulness  and  great  poverty  of  thought,  but  was 
occasionally  accompanied  by  slight,  cheerful  excitement,  also 
perhaps  by  isolated  hallucinations  and  delusions.  That  there 
was  a  state  of  even  approximate  health  in  the  intervals  was, 
however,  quite  out  of  the  question. 

Duration. — Leaving  these  peculiar  instances  out  of 
account,  cases  of  improvement  may  be  grouped  according 
to  their  duration  in  the  following  way,  if  in  the  few  patients 
whose  state  improved  several  times  we  consider  only  the 
longest  period  of  such  improvement: — 

No.  of  years  i     2     3     4     5     6     7     8     9  10  12   13   14   15   16  29 

No.  of  cases  with  )  „  , 

periodsofimpt./   -'   =^  -°  '4   '4     4     6     3     2     5     3     1     2     2     i      I 

In  the  great  majority  of  cases  therefore  the  periods  of 
improvement  do  not  last  longer  than  three  years.     Among 


COURSE    AND    REMISSIONS  183 

those  here  noted  it  was  stated  sixteen  times  without  reser- 
vation that  the  patients  had  been  completely  well.  The 
duration  amounted  in  3  cases  to  one  year,  in  2  to  two  years, 
in  4  to  three  years,  in  2  to  five  years,  in  2  to  six  years,  and 
I  to  four,  I  to  seven,  and  i  to  twenty-nine  years.  In  seven 
further  cases  the  patients  were  described  as  "quiet,"  "orderly," 
"  not  attracting  attention,"  and  were  at  least  in  a  position  to 
earn  their  own  living  again  without  difficulty  ;  it  was  a  case 
here  of  periods  of  improvement  lasting  two  to  three  years, 
I  of  four  years,  and  i  of  twelve  years.  There  were  also 
two  cases  in  which  the  patients  were  described  as  well,  but 
talkative  and  irritable  ;  in  one  of  these  cases,  in  which  already 
two  periods  of  improvement  of  several  years'  duration  had 
preceded,  the  relapse  leading  to  terminal  dementia  only 
occurred  after  fifteen  years.  In  thirty  cases  the  patients  took 
up  their  work  again  as  before,  but  appeared  quiet  and 
depressed,  or  timid  and  anxious,  possibly  also  at  times 
excited.  One  of  these  patients  passed  an  examination  well 
in  the  interval  which  lasted  nearly  three  years.  The  duration 
of  the  improvement  fluctuated  for  the  most  part  between  one 
and  ten  years ;  it  amounted  in  about  half  of  the  cases  to 
over  two  years  ;  among  these  there  were  cases  each  of  seven, 
eight,  nine,  ten,  thirteen,  and  sixteen  years. 

In  twenty-six  further  cases  there  was  to  be  noted  an 
essential  improvement  of  the  condition  but  without  the 
complete  disappearance  of  all  morbid  phenomena  ;  here  there 
were  usually  fairly  short  intervals  which  in  half  of  the  cases 
lasted  less  than  two  years.  There  were  also  ten  cases  in  which 
after  the  disappearance  of  the  more  striking  morbid  symptoms 
there  remained  a  distinct  degree  of  psychic  weakness, 
especially  emotional  dulness  and  lack  of  judgment ;  in  seven 
of  these  cases  the  improvement  did  not  exceed  three  years. 
In  a  group  of  thirteen  cases  there  remained  marked 
restlessness  and  irritability  with  a  tendency  to  passing  states 
of  excitement ;  the  duration  of  this  state,  till  a  fresh  outbreak 
occurred,  amounted  nine  times  to  over  three  years,  five  times 
to  ten  years  and  over.  Perhaps  there  might  be  added  here 
five  cases,  in  which  the  patients  during  the  period  of 
improvement  led  a  restless  life  and  became  vagrants  ;  in  only 
one  of  these  did  the  relapse  follow  in  less  than  three  years. 

In  the  cases  which  still  remain,  from  which  ten  must  be 
deducted,  about  which  no  sufficient  information  was  forth- 
coming, the  morbid  phenomena  were  even  in  the  intervals 
still  more  severe.  Some  of  these  patients  were  indeed  quiet, 
but  wholly  unoccupied  and  stayed  a  great  deal  in  bed  ;  others 
still  gave  utterance  to  delusions  or  suffered  from  hallucinations ; 


i84  DEMENTIA    PR^ECOX 

strictly  they  ought  not  to  be  counted  with  those  who  had 
periods  of  essential  improvement  at  all.  Leaving  them  aside, 
we  come  to  the  conclusion,  that  i2-6  per  cent,  of  the 
improvements  bore  the  stamp  of  complete  recovery,  which, 
however,  only  seldom  lasted  longer  than  three  to  six  years. 
Among  all  the  cases  ultimately  leading  to  dementia  the  pro- 
portion of  these  periods  of  improvement  resembling  recovery 
only  amounted  to  about  2'6  per  cent.,  or  in  a  somewhat  wider 
acceptation  to  4"i  per  cent.  If  we  take  all  those  cases 
together  who  were  able  to  live  in  freedom  without  difficulty, 
and  to  earn  their  living,  the  proportion  would  rise  to  I3'3  per 
cent.,  and  it  would  mount  to  about  17  per  cent.,  if  those 
patients  were  also  counted,  who,  it  is  true,  have  experienced 
a  distinct  change  of  their  personality,  but  still  are  to  a  certain 
extent  able  to  live  in  freedom.  The  remainder,  without 
regard  to  the  cases  which  were  not  sufficiently  elucidated, 
consists  of  those  patients  who  indeed  did  not  require  further 
institutional  care,  but  still  on  account  of  remaining  disorders 
were  not  able  to  manage  without  special  care. 

When  the  patients  again  fall  ill,  it  is  frequenth'  in  the 
same  form  as  the  first  time,  but  sometimes  it  takes  one  of  the 
other  forms  described  above.  Indeed  this  alternation  of 
clinical  forms,  which  is  occasionally  noticed, — depression, 
excitement,  stupor,  paranoid  states,  is,  as  in  manic-depressive 
insanity,  an  important  proof  of  their  inner  connection.  The 
disorders  may,  according  to  the  kind  of  relapse,  appear  again 
slowly,  acutely  or  subacutely.  Not  at  all  infrequently  there 
is  seen,  as  in  the  first  attack,  after  the  initial  improvement  a 
gradual  deterioration  of  the  psychic  state  developing  very 
slowly,  till  years  afterwards  more  severe  morbid  phenomena 
appear. 


CHAPTER   VII. 

ISSUE-TERMINAL  STATES. 

The  consideration  of  states  of  improvement  is  of  the 
greatest  importance  for  the  question  of  general  prognosis^  in 
dementia  precox.  "  According  to  my  former  grouping  into 
hebephrenic,  catatonic  and  paranoid  forms  I  had  come  to  the 
conclusion  that  in  about  8  per  cent,  of  the  first  and  in  about 
13  per  cent,  of  the  second  group,  recovery  appeared  to  take 
place,  while  paranoid  forms  probably  never  issue  in  complete 
recovery.  These  statements  have  been  much  disputed.  The 
differences  of  opinion  have  certainly  more  to  do  with  the 
limitation  of  what  is  to  be  regarded  as  recovery.  Meyer 
found,  when  he  followed  their  fate,  20  to  25  per  cent,  of  his 
patients  "  with  catatonic  phenomena  "  so  far  restored  after  a 
few  years  that  they  could  follow  their  calling  and  appear 
healthy  to  their  neighbours.  Racke,  who  after  three  to 
seven  years  made  enquiries  about  his  cases,  found  that  of  171 
catatonics  i5'8  per  cent,  might  be  regarded  as  "practically 
well,"  a  number  which  does  not  materially  diverge  from  my 
statement.  Kahlbaum  found  recovery  in  one-third  of  the 
cases  of  catatonia.  On  the  other  hand  Albrecht  reports  that 
among  his  cases  of  hebephrenia  no  real  cure  was  observed  ;  in 
catatonia  and  in  paranoid  dementia  on  the  contrary  a  few 
cases  of  recovery  occurred.  Stern  saw  recovery  in  dementia 
prgecox  in  3'3  per  cent,  of  his  cases  ;  Mattauschek  observed 
recovery  in  hebephrenia  in  2'3  per  cent.,  in  his  depressive 
paranoid  form  in  in  per  cent.,  in  the  catatonic  form  in  55  per 
cent.,  in  real  catatonia  in  4  per  cent., and  in  dementia  paranoides 
no  recoveries  at  all.  Zendig  in  his  investigations  arrived  at  the 
view  that  not  a  single  genuine  case  of  dementia  praecox  could 
be  regarded  as  really  completely  recovered  ;  Zablocka  also 
has  taken  up  this  view  in  his  report  on  515  cases.  Schmidt 
who  had  over  455  histories  at  his  disposal,  states  that  in  57*9 
per  cent,  dementia  had  supervened,  in  I5'5  per  cent,  recovery 
with  defect,  and  in  i6'2  per  cent,  a  cure  ;  the  remainder  had 
died. 

'  Meyer,  Miinchener  medizin.  Wochenschr.  1903,  1369  ;  Racke,  Archiv.  f. 
Psychiatric  xlvii.  i  ;  Mattauschek,  Jahrb,  f.  Psychiatric,  xxx.  69 ;  Schmidt, 
Zeitschr.  f.  d.  gcs.  Neurologic  u.  Psychiatric  vi.  2,  125. 


i86  DEMENTIA    PR/ECOX 

There  are  various  grounds  for  the  contradictory  nature  of 
these  statements.  In  the  first  rank  of  course  the  delimita- 
tion of  dementia  pnecox  comes  into  consideration.  We 
shall  see  later  that  on  this  point,  in  spite  of  the  ease  with 
which  the  i^reat  majority  of  the  cases  can  be  recognized, 
there  is  still  great  uncertainty.  This  is  true  in  regard  chiefly 
to  the  placing  of  the  paranoid  forms  which  are  reckoned  with 
dementia  pnecox  sometimes  to  a  greater,  sometimes  to  a 
smaller,  extent,  as  also  in  regard  to  cases  in  advanced  age 
in  which  likewise  the  arrangement  in  proper  order  in  our 
morbid  history  may  be  variously  handled.  As  in  general  the 
widening  of  the  limits  in  both  directions  increases  the  number 
of  cases  which  are  prognostically  unfavourable,  there  are  here 
some  causes  for  the  variation  of  the  figures  got  for  recovery. 

Further  difficulties  arise  from  the  varied  delimitation 
towards  the  domain  of  amentia^  and  of  manic-depressive 
insanity.  The  cause  of  that  lies  in  the  imf)ortance,  some- 
times greater,  sometimes  less,  which  is  attributed  to  the 
appearance  of  the  so-called  "catatonic"  morbid  symptoms 
about  the  extent  of  which,  moreover,  opinions  are  likewise 
varied.  In  any  case  there  still  exists  to-day  to  a  not  incon- 
siderable extent  the  possibility  of  cases  of  amentia  and  of 
manic-depressive  insanity  being  wrongly  attributed  to 
dementia  praicox  and  vice  versa ;  the  prognosis  of  the 
disease  will  accordingly  be  more  favourable  or  more  un- 
favourable. 

In  this  uncertainty  about  the  delimitation  the  statements 
of  different  observers  can  in  the  first  place  not  be  compared 
at  all,  not  even  the  diagnoses  of  the  same  investigator  at 
different  periods  of  time  separated  by  a  number  of  years. 
But,  even  if  this  difficulty  did  not  exist,  we  should  further 
have  first  to  agree  about  the  idea  oi  cure.  To  begin  with,  the 
degree  of  recovery  must  be  taken  into  account.  Me\*er 
evidently  docs  not  make  the  very  strictest  claims,  and  Racke 
speaks  frankly  of"  practical  "  cures.  But  in  dementia  praicox 
in  a  considerable  nuinber  of  cases  all  the  more  striking 
morbid  phenomena  may  disappear,  while  less  important 
changes  of  the  psychic  personality  remain,  which  for  the  dis- 
charging of  the  duties  of  life  have  no  importance,  but  are 
perceptible  to  the  careful  observer,  who  need  not  always  be  a 
relative.  As  the  most  manifold  transitions  exist  between 
coinplete  disappearance  of  all  the  disorders  and  the.se  cases  of 
"  recovery  with  defect,"  the  delimitation  of  recovery  in  the 
strictest  sense  is  to  a  certain  extent  arbitrary,  but  just  as  much 
so  also  the  determination,  where  "practical"  cure  passes  into 
distinct  psychic  decline.     On  this  account  also  the  figures  of 

'  .Sec  note  on  p.  275. 


ISSUE— TERMINAL   STATES  .     187 

different  investigators  will  of  necessity  diverge  from  one 
another.  Further  also  there  is  the  possibility  that  in  certain 
circumstances  slight  peculiarities  which  were  already  present 
before  the  patient  fell  ill,  but  which  had  remained  unnoticed, 
or  which  are  dependent  on  other  conditions,  may  be  wrongly 
regarded  as  consequences  of  dementia  prxxox. 

But  lastly,  attention  must  be  directed  to  improvement 
with  later  relapse,  which  has  already  been  treated  in  detail. 
As  improvement,  which  resembles  recovery,  may  certainly 
persist  far  longer  than  a  decade,  we  shall  be  able  to  pronounce 
a  final  judgment  about  the  issue  of  an  apparently  cured  case 
only  after  a  very  long  time,  and  must  even  after  ten  or  twenty 
years  make  up  our  minds  to  having  few  cases  verified.  In 
the  majority  of  the  researches,  hitherto  communicated,  the 
time  which  has  passed  since  the  commencement  of  the 
improvement  is  much  too  short  for  the  figures  to  give  now  a 
final  decision  on  the  prognosis  of  dementia  pracox.  Meyer, 
indeed,  has  taken  up  the  standpoint  that  in  relapses  after  a 
considerable  time  we  have  to  do  with  fresh  attacks  of  the 
disease  and  thus  are  quite  justified  in  speaking  of  recoveries. 
It  might,  however,  considering  the  many  gradations  in  the 
length  of  the  intervals,  and  in  the  severity  of  the  slighter 
morbid  symptoms  which  continue  during  their  course,  be 
quite  impossible  to  determine  the  point  when  we  no  longer 
have  to  do  with  a  flaring  up  of  the  morbid  process  which  has 
been  so  long  at  a  standstill,  but  with  a  really  fresh  attack  of 
the  disease.  Later  we  shall,  moreover,  learn  still  other 
grounds  which  give  evidence  of  an  inner  connection  between 
attacks  which  are  similar  to  each  other  though  separated  by 
considerable  intervals  of  time. 

It  is  the  difficulties  here  explained  in  detail  which  cause 
me  for  the  moment  to  refrain  from  laying  down  new  values 
for  the  prospects  of  cure  in  dementia  prsecox.  In  any  case 
for  a  very  considerable  number  of  apparently  cured  cases  it  will 
not  be  possible  to  bring  forward  now  with  any  certainty  the 
objection  that  it  was  a  case  of  mistaken  diagnosis  or  of 
temporary  improvement  which  later  was  followed  by  relapse. 
On  the  other  hand  it  will  not  be  possible  at  the  outset  to 
deny  the  possibility  of  complete  and  lasting  cure  in  dementia 
praecox.  If  a  morbid  process  can  remain  quiescent  for 
twenty-nine  years,  as  in  one  of  the  cases  observed  by  myself, 
it  will  probably  be  able  also  to  attain  to  a  complete  cure. 
Still,  the  severe  relapses  after  comparatively  long  and 
perfectly  free  intervals  must  suggest  the  thought  that,  as  in 
paralysis,  we  have  often  to  do  only  with  a  standstill  or  with 
extremely  slow  progress,  but  not  with  a  real  termination  of 


i8S  DEMENTIA   PR/ECOX 

the  morbid  process.  The  experience,  is,  however,  worthy  of 
notice,  that  even  amoiii^  the  cases  which  terminate  unfavour- 
ably, wliich  form  the  foundation  of  my  cHnical  statements, 
many  forms  in  a  third  of  the  cases,  indeed  in  more  than  half, 
exhibit  marked  improvement,  but  which  gives  wa}'  sooner  or 
later  to  a  relapse.  As  the  frequency  of  essential  improvement 
in  any  other  disease  could  scarcely  be  much  greater,  it  may 
reasonabh'  be  thought  that  the  cases  terminating  unfavour- 
ably, which  I  selected,  on  the  whole  represent  the  general 
behaviour  of  dementia  praico.x.  Further  researches  into 
extensive  series  of  cases  observed  carefully  throughout 
decades  must  show  how  far  the  view,  which  is  gaining  in 
probability  for  myself,  is  right,  that  lasting  and  really 
complete  cures  of  dementia  pr^ecox,  though  they  may  perhaps 
occur,  still  in  any  case  are  rarities. 

An  almost  immeasurable  series  of  intermediate  steps  leads 
from  cure  in  the  strictest  sense  to  the  most  profound 
dementia.  According  to  my  former  statements  17  per  cent, 
of  the  hebephrenic  and  27  per  cent,  of  the  catatonic  form 
seemed  to  me  to  issue  in  a  moderate  degree  of  weak-minded- 
ness, while  profound  dementia  occurred  in  the  former  in  75 
per  cent,  of  the  cases,  in  the  latter  in  59  per  cent.  Among 
other  observers  Zablocka  found  for  hebephrenia  in  58  per 
cent,  of  the  cases  slight,  in  21  per  cent,  medium,  in  21  per 
cent,  high  grade  dementia  ;  the  corresponding  values  for 
catatonia  were  58  per  cent.,  15  per  cent,  and  27  per  cent. 
Mattauschek  reports  for  hebephrenia  over  9"3  per  cent, 
recoveries  with  defect,  209  per  cent,  dementia  of  the  first 
grade,  67*4  per  cent,  dementia  of  severer  degree.  For  his 
"depressive  paranoid"  cases  the  figures  amount  to  in  per 
cent.,  24-1  per  cent.,  and  53*7  per  cent.;  for  his  "catatonic 
forms"  138  per  cent.,  25  per  cent.,  55*5  per  cent.;  in 
catatonia  1 2  per  cent.,  20  per  cent.,  and  64  per  cent.  Albrecht 
found  recovery  with  defect  in  hebephrenics  in  125  per  cent, 
simple  dementia  in  27  per  cent.,  high  grade  dementia  of 
different  kinds  in  60  per  cent,  of  the  cases ;  for  catatonia  the 
results  were  in  24  per  cent,  of  the  cases  simple,  in  50 
per  cent,  severe  dementia.  Stern  established  as  issue  in 
dementia  pnecox  in  367  per  cent,  slight,  in  18*3  per  cent, 
medium,  and  in  417  per  cent,  severe  dementia.  Evensen 
states  that  of  his  hebephrenics  5  per  cent,  remained 
independent,  25  per  cent,  at  least  still  capable  of  work,  and  70 
per  cent,  profoundly  demented ;  among  the  catatonics  only 
50  per  cent,  became  quite  insane.  I  have  invariably  seen  the 
jjaranoid  cases  issue  in  states  of  weak-mindedness,  which  in 
about  half  of  the  cases  were  of  slighter  degree,  in  the  other 


ISSUE— TERMINAL   STATES  189 

half  of  severer  dej^ree.  Simple  weak-mindedness  without 
other  more  striking  morbid  phenomena  was  the  result  in  only 
7  per  cent,  of  the  cases.  Mattauschek  notes  as  terminal 
states  in  these  forms  in  2 11  per  cent,  of  the  cases  slighter, 
in  78"9  per  cent,  severer  dementia  ;  Zablocka  in  65  per  cent, 
slight,  in  16  per  cent,  medium,  in  29  per  cent,  profound 
dementia.  A Ibrecht  states  that  for  the  most  part  hallucinatory- 
weak-mindedness  was  the  end  of  the  disease,  occasionally  also 
simple  dementia,  recovery  with  defect,  hallucinatory  insanity, 
or  even,  as  already  mentioned,  cure. 

As  can  be  already  recognized  from  this  summary  the 
statements  of  the  individual  investigators  are  at  present  not 
at  all  comparable.  To  the  uncertainty  of  the  diagnosis 
there  have  to  be  added  the  divergent  grouping  of  the  forms 
and  the  various  judgments  of  the  terminal  states.  It  is 
indeed  in  high  degree  arbitrary  how  many  grades  of  dementia 
may  be  distinguished,  and  how  the  individual  cases  may  be 
distributed  among  them,  especially  as  their  condition  may 
still  often  experience  after  a  long  time  all  kinds  of  transforma- 
tion. The  grouping  of  the  terminal  states  according  to  the 
morbid  phenomena  which  principally  appear  in  them,  as  has 
already  been  attempted  in  the  foregoing  presentation,  perhaps 
offers  a  somewhat  better  prospect  of  scientific  usefulness. 
Here  also  the  placing  of  the  individual  case  will  doubtless  be 
often  uncertain  ;  still  this  classification  at  least  brings  the 
terminal  states  into  closer  relations  to  the  preceding  clinical 
pictures. 

Simple  Weak-mindedness. 

The  first  form,  which  from  this  point  of  view  we  may 
delimit,  is  simple  weak-mindedness  without  other  striking 
morbid  phenomena.  The  weakness  lies,  corresponding  to 
the  principal  points  of  attack  of  the  disease,  specially  in  the 
domain  of  emotion  and  volition;  to  a  less  degree  judgment 
and  still  less  memory  are  involved.  After  the  disappearance 
of  the  more  marked  morbid  symptoms  the  patients  seem  to 
be  clear  about  time,  place,  and  person,  also  about  their  position, 
p.nd  give  reasonable  and  connected  information.  Hallucina- 
tions disappear  in  the  main,  especially  the  voices  ;  only  now 
and  then  perhaps  "  hissing  sounds  "  occur  still  once  in  a  way, 
or  the  patient  sometimes  hears  his  name  called,  but  with  an 
effort  can  get  away  from  it,  does  not  pay  attention  to  it  any 
longer.  Recollection  of  the  time  of  the  disease  is  usually 
clouded.  Still  the  patient  knows  that  he  has  heard  "  inward 
voices,"  thought  he  was  in  heaven,  was  anxious.  He  also 
states  that  now  his  head  is  not  being  electrified  any  longer,. 


I90  DEMENTIA    PR.-ECOX 

that  the  voices  have  stopped,  and  he  denies  more  or  less 
definitely  tiie  former  delusions;  he  "won't  be  a  guardian- 
an;^el  any  lonijer,"  "  can't  work  any  miracles." 

Understanding  of  the  significance  of  the  morbid  pheno- 
mena is  at  the  same  time  often  very  defective.  The  patient 
perhaps  admits  that  he  has  been  confused,  has  been  suffering 
from  his  nerves,  but  considers  the  illness  that  he  has  passed 
through  quite  harmless,  and  himself  quite  well  ;  and  he  does 
not  feel  any  need  of  enquiring  further  about  the  nature 
of  his  disease  and  its  course.  Many  patients  connect  their 
morbid  conduct  with  chance  external  causes,  wrong  treat- 
ment by  relatives,  life  in  the  institution  ;  "  It  was  only 
dissimulation,"  said  a  patient.  Sometimes  perhaps  even  a 
few  delusions  which  have  arisen  during  the  course  of  the 
disease  are  retained  uncorrected,  though  the  patients  do  not 
speak  of  them  any  longer,  and  do  not  let  themselves  be 
influenced  by  them  any  longer. 

Alsx:)  in  other  directions  a  distinct  weakness  of  judgment 
appears  as  a  rule.  The  patients  have  become  incapable  of 
taking  a  general  view  of  more  complicated  relations,  of 
distinguishing  the  essential  from  side  issues,  of  foreseeing 
the  consequences  of  their  own  or  other  people's  actions. 
Their  circle  of  ideas  appears  to  be  narrowed.  .Although 
occasionally  still  a  considerable  residuum  of  knowledge 
formerly  acquired  ma)-  come  to  the  surface,  \"et  the  patients 
have  lost  the  capability  of  making  use  of  it,  and  of  working 
with  it,  a  circumstance  which  naturally  brings  about  its  loss 
by  degrees.  The  patients  therefore  lo.se  a  great  part  of 
their  knowledge ;  they  become  impoverished  in  thought, 
monotonous  in  their  mental  activities.  As  at  the  same  time 
their  attention  is  blunted,  they  have  but  little  inclination  or 
ability  to  learn  anything  new,  to  pursue  aims,  to  carry  out  a 
more  extended  plan.  "  She  has  no  memory  at  all  when  she 
works,"  the  father  of  a  patient  wrote;  '"He  hasn't  got 
enough  sense,"  another  rejjorted  about  his  son.  In  slighter 
cases,  however,  acquired  proficiency  remains  fairl\'  well 
jjreserved.  Many  patients  play  cards  or  chess  well  ;  others 
can  do  arithmetic,  draw  and  write  with  great  perseverance, 
but  are  perhaps  quite  incapable  of  appreciating  corrections, 
mistakes  in  spelling,  or  interpolations  properly,  or  of  planning 
anything  themselves. 

Mood  may  be  of  very  various  colouring.  The  lack  of 
deep  emotion,  however,  is  the  characteristic  feature.  The 
patients  regard  with  indifference  the  events  of  life,  live  a  day 
at  a  time  without  endeav^our,  without  wishes,  without  hopes 
or  fears.     A  patient  replied  to  the  question,  whether  he  did 


ISSUE— TERMINAL   STATES  191 

not  wish  to  return  home,  "  It  is  the  same,  whether  I  stand 
about  here  or  there."  The  relation  to  their  relatives  becomes 
cool,  sometimes  directly  hostile;  former  interests  are  weakened 
or  extinguished  ;  work  is  accomplished  mechanically  with- 
out inward  participation.  At  the  same  time  the  patients 
frequently  exhibit  depressed,  suspicious  behaviour,  not  very 
accessible,  at  times  irritable  and  sensitive,  occasionally  accom- 
panied by  ideas  of  jealousy.  They  must  "  be  treated  with 
love  and  consideration,"  as  one  of  the  patients  put  it.  Other 
patients  are  cheerful,  untroubled,  confiding,  erotic;  often  there 
is  a  tendency  to  laughing  and  smirking  without  recognizable 
cause. 

The  Outward  Conduct  of  the  patients  is  in  general 
reasonable ;  only  they  often  exhibit  a  stiff  constrained 
demeanour  or  a  somewhat  odd  behaviour,  singular  clothing, 
neglect  of  their  person,  small  peculiarities  in  speech,  gait  and 
movement.  One  of  my  physicians  noticed  a  young  mason 
who  in  placing  the  stones  turned  them  in  a  curious  way  ;  it 
was  a  patient  of  our  hospital  who  was  "  cured  with  defect." 
In  a  few  patients  there  remain  indications  of  automatic 
obedience.  Many  patients  are  quiet,  taciturn,  constrained*,  shy, 
withdraw  themselves,  avoid  people  ;  they  appear  obstinate, 
unresponsive,  intractable,  do  not  go  any  more  to  church  or 
public-house,  always  sit  on  the  same  chair,  stare  in  front  of 
them.  Others  on  the  contrary  are  childishly  intimate,  access- 
ible, docile,  but  not  independent ;  others  again  display  signs 
of  slight  excitement,  grumble,  try  to  get  away,  are  prolix, 
somewhat  incoherent  in  their  talk,  over-polite,  abusive  at 
times,  occasionally  perpetrate  nonsensical  actions,  destroy 
anything,  throw  their  watch  into  the  water-closet,  compose 
confused  documents,  fall  into  drinking  habits.  One  of  my 
female  patients,  who  up  till  then  had  been  a  respectable  girl, 
gave  birth  in  a  remission  of  five  years'  duration  after  severe 
catatonic  excitement  to  three  illegitimate  children,  the  last 
of  which  she  smothered  by  carelessness  ;  during  detention 
there  then  occurred  a  fresh,  very  violent  attack  of  catatonic 
excitement  which  led  to  simple  dementia  ;  seven  }'ears  later 
in  the  institution  she  again  passed  through  a  severe  attack 
of  excitement  which  passed  off  rapidly. 

Capacity  for  work  is  as  a  rule  diminished.  Many 
patients,  it  is  true,  are  diligent,  but  cannot  be  set  to  every 
kind  of  work  :  "  The  will  to  work  is  perfectly  good,  but 
accomplishment  is  deficient,"  wrote  the  relatives  of  a  patient. 
Sometimes  they  make  very  peculiar  and  useless  things. 
Their  previous  employment  has  very  frequently  become  too 
difficult  for  them  ;  they  look  out  for  easier  work.     The  former 


192  DEMENTIA    PRECOX 

fine  mechanician  becomes  a  simple  locksmith,  the  student  a 
copyist,  the  artisan  a  day-labourer.  There  is  no  question 
of  deliberate  endeavour  to  make  good  use  of  or  to  improve 
their  own  condition.  They  live  a  day  at  a  time,  squander 
what  they  earn,  take  no  thought  for  the  future.  Some 
patients  absolutely  refuse  to  work,  loiter  about  aimlessly, 
take  walks,  stay  in  bed  for  days.  Not  infrequently  a  very 
great  need  for  sleep  is  observed,  also  considerable  appetite, 
while  other  patients  must  always  be  pressed  to  eat.  "  Half 
nourishment  is  enough,"  said  a  patient.  Complaints  about 
headache  are  frequent. 

The  degree  of  development  reached  by  the  morbid  pheno- 
mena which  have  been  described  of  course  varies  to  a  very 
great  extent.  In  numerous  cases  the  changes  are  so  trifling 
that  they  can  only  be  recognized  by  those  in  close  contact 
with  the  patient  and  only  by  good  observers.  The  patient 
has  merely  become  a  little  quieter  and  more  self-willed,  more 
capricious  ;  he  appears  more  absent-minded,  more  indifferent, 
gives  up  the  execution  of  more  ambitious  plans,  works  more 
mechanically,  but  is  able  to  fulfil  the  usual  claims  of  the  day 
quite  well.  If  one  will,  one  may  here  speak  of  a  "  practical " 
recovery,  although  a  complete  and  radical  cure  of  the  morbid 
process  has  not  taken  place,  as  is  then  proved  by  occasional 
fairly  severe  relapses.  But  even  the  more  marked  forms  of 
this  simple  weak-mindedness  usually  exhibit  no  very  striking 
psychic  morbid  picture  and  are  often  enough  regarded  from 
the  point  of  view  of  moral  offence,  especially  when  they  have 
developed  slowly.  This  is  seen  in  those  patients  who  sink  in 
an  apparently  incomprehensible  manner  from  the  position  in 
which  birth  and  breeding  had  placed  them,  indeed  in  certain 
circumstances  to  be  habitual  criminals,  vagrants,  prostitutes, 
without  the  morbid  nature  of  the  change  which  is  taking 
place  in  them  being  recognized.  This  accounts  for  the 
frequency  with  which  more  marked  morbid  states  are 
developed  in  them  when  after  a  restless  life  full  of  excite- 
ment, privation  and  excesses,  loss  of  freedom  brings  on  them 
still  further  severe  injury. 

Hallucinatory  Weak-mindedness. 

Next  to  simple  weak-mindedness  there  come  perhaps  those 
forms  of  psychic  decline,  in  which  as  residuum  of  the  disease 
through  which  they  have  passed,  besides  a  more  or  less 
severe  loss  in  mental  capacity,  some  hallucinations  are  still 
left,  which  are  regarded  by  the  patient  himself  as  morbid 
phenomena  or  at  least  are  not  further  elaborated. 


ISSUE— TERMINAL  STATES  193 

Auditory  Hallucinations  play  the  principal  part  Some- 
times only  very  occasionally,  sometimes  more  frequently,  but 
still  always  with  great  fluctuation,  they  torment  the  patient ; 
sometimes  they  occur  specially  at  night.  What  the  voices 
say  frequently  consists  of  fragmentary  cries,  which  are  often 
repeated  in  the  same  phrases  and  are  sometimes  quite  in- 
different, sometimes  mocking,  even  perhaps  nonsensical  or 
incomprehensible,  occasionally  in  a  foreign  language.  Other 
patients  hear  question  and  answer  or  whole  conversations  ;  at 
the  same  time  noises,  murmurings,  knockings,  are  perceived. 

The  hallucinations  of  hearing  of  the  patient  have  mostly  a 
certain  connection  with  his  train  of  thought,  though  some 
utterances  appear  wholly  bewildering  and  unconnected.  "  I 
was  never  wholly  free  from  the  idea,  that  a  strange  person 
was  interfering  in  my  mental  sphere,"  wrote  a  patient  who  at 
the  time  had  been  in  a  responsible  position  in  life  for  more 
than  twenty  years  without  any  morbid  symptom  ;  "Thoughts 
flash  up  at  times  without  my  seeking  them  at  all."  Another 
patient  describes  his  disorders  very  vividly  who  likewise,  after 
passing  through  an  acute  attack  fifteen  years  ago,  has  been 
continuously  diligent  in  his  calling  though  with  much  inward 
difficulty : 

"The  utterances  accompany  my  own  thinking,  but  in  such  a  way 
that  I  always  can  separate  them  from  it.  Sometimes  they  are  mixed 
with  the  formation  of  thought  itself ;  that  is  then  specially  tormenting, 
and  the  more  tormenting  the  shorter  the  moment  is  between  my  thoughts 
and  the  corresponding  utterance  of  the  voices.  As  regards  what  they 
say  the  voices  bring  professed  news  about  everything  possible  and 
impossible,  the  Emperor,  the  Crown  Prince,  their  consorts,  my  superiors 
and  colleagues  and  their  families,  relations  and  friends  and  also  about 
my  chance  surroundings.  Sometimes  I  have  the  impression,  as  if 
certain  persons,  known  and  unknown,  could  become  aware  of  my 
thoughts,  were  inwardly  encountering  me  in  a  friendly  or  hostile  manner. 
As  I  fear  that  from  such  thoughts  mania  of  persecution  might  arise, 
I  oppose  them  with  all  the  power  of  logic." 

Here  unmistakably  it  is  a  case  of  the  same  disorders 
which  we  have  met  with  so  often  in  the  description  of  the 
clinical  morbid  pictures.  It  is  only  the  attitude  of  the  patient 
towards  the  hallucinations  that  has  changed,  a  sign  that  we 
have  only  to  do  with  a  limited  residuum  of  the  former  malady 
and  no  longer  with  a  morbid  state  of  the  whole  personality. 

An  excellent  view  of  these  processes  is  given  by  the 
following  notes  written  by  the  same  patient  of  what  he 
heard  at  intervals ;  among  them  the  questions  which  were 
inwardly  directed  to  the  voices  by  the  patient  are  given 
in  parentheses  :— 

(Why  are  you  speaking  in  me  ?  )  "  You  may  eat  blood.  A.  must 
laugh  at  you.     Because  we  are  poor  blockheads.     Asylum.     We'll  bring 

N 


194  DEMENTIA   PRECOX 

you  later  to  an  asylum.  O  my  dear  genius  I  Because  we  are  hypochon- 
driacs. 1  am  your  poor  marmot.  We  are  the  mistresses  of  the  German 
whipping-club.  We  inhale  you."  (Why  do  you  torment  me?)  "Have 
you  a  fate  I  We  think  the  best  of  you.  Taraxacum  !  Taraxacum  ! 
We  thrash  Dr  S.'s  bones  bloody  for  he  has  become  surety  for  you. 
Because  we  are  frightfully  fond  of  you.  What  am  I  to  do  ?  We  weep 
laughing  tears.  We  are  differently  developed.  O  you  my  darling  little 
Jesus.  Because  we  ourselves  are  tormented.  Because  we  morally  act 
perversely.  We  have  christian  catholic  morality.  Every  human  being 
must  laugh  at  you.  You  are  mentally  ill.  Yes,  it  is  so.  Because  we 
have  to  fear  your  brain  grease.  O  wild  sheikh  Almagro  !  Whom  one 
loves,  one  torments.  We  have  no  implements  of  handicraft.  You  are  in 
many  things  an  absolute  child,  an  absolute  fool  1  We  torment  you  as 
moral  rapscallions!"  (What  is  your  real  object.'')  "We  wish  to  kill 
you.  You  have  offended  divine  providence.  Our  object  is  morally 
irrelevant.  M.  must  laugh  at  you.  Our  object  is  your  cleansing.  But 
Absalom  I  We  love  and  hate  you.  Our  object  is  terrible  establishment 
of  women's  regiment.  We  are  silly."  (Are  you  human  beings  or 
spirits?)  "We  are  human  beings,  old  topswine  !  O  that  needs  an 
insane  patience  I  I  will  show  you  my  last  aims.  We  weep  about  you. 
You  have  been  very  prudent.  We  are  climbing  up  Ararat.  Now  then, 
little  spirits  !  Little  folk,  brownies  I  You  are  fundamentally  insanely 
deep  I  "  (Shall  I  get  well  again  ?)  "  Not  according  to  the  plan  of  the 
women's  regiment.  Now  then,  no !  For  you  have  the  delusion  of 
persecution.  We  only  want  to  try  you.  You  are  not  mentally  ill. 
Have  you  then  no  idea  of  your  significance  ?  We  are  moral  female 
anarchists.  Yes  certainly,  in  God's  counsel.  Have  you  not  delirium  ? 
For  God's  sake,  you  make  a  note  of  everything.     Haven't  you  let  loose 

the  werewolves  at  us  ?     Between  mountain  and  deep,  deep  valley " 

(.A^re  you  near  1)     "  No,  far  away.     What  shall  we  do  contrary  to  your 
interests  ?     No,  in  the  middle  of  your  head  ! '" 

These  notes,  which  reproduce  about  the  half  of  what  was 
heard  in  an  hour,  let  it  be  seen  that  the  voices  answer  the 
questions  inwardly  addressed  to  them,  though  not  always 
immediately.  In  between  are  interpolated  all  possible  dis- 
connected remarks  and  exclamations.  In  many  of  these 
utterances  the  personal  attitude  taken  up  by  the  voices 
towards  the  patient  appears  distinctly,  as  we  observed  it  at 
the  height  of  the  disease  in  connection  with  ideas  of  persecu- 
tion and  exaltation.  The  voices  mock,  deride,  threaten  the 
patient  and  his  friends,  reproach  him,  bewail,  praise  and 
admire  him  ;  they  indicate  that  they  have  power  over  him 
and  dwell  as  spirits  in  him.  Along  with  this  a  marked 
morbid  feeling  makes  itself  noticeable  in  the  phrases  about 
asylum,  mental  disease,  delirium,  mania  of  persecution. 

Visual  Hallucinations  usually  play  a  smaller  part. 
Many  patients  .see,  especially  in  sleepless  nights,  all  possible 
figures,  effects  of  light,  or  objects  appear  distorted.  Other 
patients  have  pictures  of  individuals  forced  on  them,  some- 
times with,  .sometimes  without,  connection  with  their  other 
trains   of  thought.      Occasionally   also   all    .sorts   of  bodily 


ISSUE— TERMINAL   STATES  195 

dySc'Esthesiae  are  reported,  especially  oppression  in  their  head 
and  sensations  of  giddiness. 

Mood  is  mostly  depressed.  The  patients  feel  themselves 
tormented,  inwardly  constrained,  hindered  in  their  capacity 
for  work  ;  they  incline  often  to  painful  self-observation,  make 
complaints  about  sleeplessness,  digestive  disorders,  states  of 
anxiety.  Many  patients  learn  gradually  to  come  to  terms 
with  their  troubles  in  some  measure,  and  by  a  prudent  and 
regular  life  and  avoidance  of  greater  exertions,  excitement 
and  excesses,  to  preserve  their  capacity  for  work.  Even  in 
them,  however,  a  quiet,  shy,  reserved  behaviour  usually 
accompanies  the  loss  of  self-confidence  and  independent 
energy,  which  results  from  the  continuance  of  the  morbid 
residua.  "  My  success  in  controlling  my  disease  I  owe 
principally  to  my  own  self-restraint  and  to  taking  measures 
for  my  state  as  soon  as  it  becomes  intolerable,"  wrote  a 
patient. 

In  other  cases  the  damage  to  the  psychic  personality 
goes  much  deeper,  even  to  the  production  of  marked  weak- 
mindedness.  The  patients  do  not  correct  the  hallucinations, 
but  they  do  not  speak  about  them  any  longer  ;  they  do  not 
listen  to  the  voices  any  longer,  do  not  get  excited  about 
them  ;  "  that's  useless,  there's  no  aim  in  it."  Many  patients 
are  probably  still  irritated  temporarily  by  the  "  voices  of 
persecution,"  abuse  them,  especially  at  night,  stop  their  ears, 
speak  now  and  then  low  to  themselves,  but  between  times  do 
not  wish  to  know  anything  more  of  them,  go  on  with  their 
work  without  disturbance.  At  the  same  time  there  is  invari- 
ably found  a  greater  or  less  narrowing  of  interests,  a  weaken- 
ing of  emotional  relations,  a  loss  of  volitional  activity,  often 
also  a  repellent,  reserved  behaviour. 

Paranoid  Weak-mindedness. 

Obviously  those  terminal  forms  of  dementia  prsecox,  in 
which  uncorrected  delusions  continue  to  exist,  injure  the 
psychic  life  essentially  more  profoundly  than  the  "  hallucina- 
tory weak-mindedness"  above  described.  We  met  them  as  the 
invariable  terminal  states  of  "dementia  paranoides  mitis," 
but  they  come  under  observation  here  and  there  as  the  issu  e 
of  other  forms  conjoined  with  delusions,  though  perhaps  in 
somewhat  divergent  form.  Above  everything  it  is  ideas  of 
persecution  which  are  permanently  adhered  to  after  the  dis- 
appearance of  the  more  acute  morbid  phenomena,  mostly  in 
a  very  monotonous  way  and  without  substantial  elaboration, 
but  in    gradually   ever    more    nonsensical    and    incoherent 


196  DEMENTIA    PRECOX 

expressions.  At  the  same  time  the  most  varied  hallucina- 
tions also  usually  play  an  important  part.  It  is  the  old 
story  ;  the  persecutors  are  still  always  there.  The  patient  is 
abused,  mocked,  electrified,  stupefied,  blinded,  plagued  by 
witches  ;  by  day  and  by  night  experiments  in  physics  are 
carried  out,  specious  political  business,  rascally  tricks.  His 
children  are  being  murdered,  his  money  withheld  from  him, 
his  throat  slit  up.  Obscene  things  are  said,  his  nature  drawn 
off,  his  semen  poured  out.  The  patients  "  must  answer  the 
voices,"  must  do  what  they  command.  On  the  other  hand 
the\-  hear  voices  from  God  saying  that  they  are  Christ,  that 
they  are  queens  by  birth,  that  they  are  to  get  millions.  In 
course  of  time  the  delusions  fade  somewhat,  it  is  rather  better, 
the  patients  say.  "  Electrification  is  rather  less."  At  the 
same  time  a  certain  morbid  feeling  may  appear.  The 
patients  say  that  they  had  often  suffered  from  disorders, 
had  confused  thoughts,  cannot  work  properly,  are  a  little 
"  mentally  affected." 

About  their  surroundings  and  their  position  in  general, 
the  patients  are  usually  for  the  most  part  clear,  so  far  as 
delusional  occurrences  do  not  play  a  part.  Their  train  of 
thought  remains  fairly  connected  and  reasonable,  but  easily 
becomes  incoherent  and  confused,  as  soon  as  their  delusions 
are  suggested  and  they  fall  into  excitement. 

Mood  is  morose,  often  very  irritable,  more  rarely  dull  or 
exalted.  At  times  the  patients  become  threatening,  abusive, 
violent  ;  they  shut  themselves  up,  indulge  in  superior  irony. 
Nevertheless  they  are  often  able  to  occupy  themselves  with 
success  and  aptitude,  though  at  the  same  time  they  like  to  go 
their  own  way.  Slight  indications  also  are  often  found  of  the 
volitional  disorders  characteristic  of  dementia  pra.'cox.  The 
taciturn,  thoroughly  inaccessible,  behaviour  of  many  patients 
might  not  be  caused  only  by  their  delusions  but  at  least  partly 
by  negativistic  action  ;  in  others  we  observe  mannerisms, 
smacking  with  the  lips,  spitting,  repetition  of  questions 
addressed  to  them,  queer  ways  of  expressing  them.selves, 
singular  clothing. 

Dementia— Drivelling,  Dull,  Silly,  Manneristic, 
Negativistic. 

If  we  try  to  carry  out  the  classification  of  the  terminal 
states  according  to  the  special  characteristic  which  is  im- 
pressed on  them  by  the  permanence  of  definite  morbid 
phenomena  from  the  earlier  periods  of  the  disease,  we  shall 
be  able  to  distinguish  a  series  of  forms  in  which  sometimes 


ISSUE— TERMINAL   STATES  197 

mental  weakness,  sometimes  emotional  dulness,  sometimes 
one  of  the  peculiar  volitional  disorders  more  specially 
dominates  the  condition.  Of  course  it  is  never  a  question 
here  of  sharp  limitations,  as  little  as  in  the  various  courses  of 
the  disease  previously  described.  Much  rather  we  shall  find 
again  everywhere  the  fundamental  features  of  dementia 
pr.-Ecox,  only  that  here  the  one  peculiarity,  there  the  other, 
is  more  strongly  represented.  Clinical  relations  to  the 
former  morbid  pictures  exist  in  so  far  that  in  the  terminal 
state  only  such  symptoms  are  preserved  as  had  already  been 
developed,  but  they  may  later  even  completely  disappear. 
While  we  therefore  have  recognized  in  simple  weak-minded- 
ness an  issue  which  signifies  a  disappearance  of  all  the  more 
striking  disorders  and  therefore  in  general  a  milder  course  of 
the  malady,  there  remain  permanently  in  the  following  forms  of 
the  psychic  decline  distinct  morbid  phenomena  in  particular 
domains  of  the  inner  life.  At  the  same  time  a  considerable 
disappearance  of  the  morbid  disorders  may  take  place  in 
some  or  most  of  the  other  domains,  so  that  we  find  besides 
the  more  striking  characteristics  of  the  terminal  state,  some- 
times only  very  slight,  but  sometimes  also  very  deeply- 
spreading  changes  in  the  rest  of  the  psychic  personality. 

Drivelling  Dementia. — If  in  the  "paranoid"  terminal 
states  we  had  to  do  essentially  with  a  continuance  of  the 
delusional  morbid  processes,  the  characteristic  of  drivelling 
dementia  is  the  general  decay  of  mental  efficiency.  Here  also 
are  still  found,  as  a  rule,  hallucinations  and  delusions,  the 
senselessness  of  which  distinctly  proves  the  mental  weakness. 
The  patients  hear  the  voices  of  devils,  spirits  calling,  are 
tormented  by  senseless  telephoning;  thoughts  are  blown  into 
them ;  they  speak  with  the  voices.  They  are  influenced, 
bled  every  evening,  have  their  genitals  pulled  at,  are  pressed 
together,  sucked  out  through  a  needle,  castrated,  punctured  ; 
they  are  beaten  on  their  heads  at  night  with  an  iron  hammer  ; 
they  smell  blood  and  corpses.  The  doctors  procure  abortion  ; 
the  connection  between  the  uterus  and  the  rectum  is  gone, 
their  flesh  is  adulterated.  Little  children  are  sitting  in  their 
neck  ;  the  female  sexes  have  suffered  very  great  want ;  there 
is  quackery  going  on,  subterranean  vapour  business,  silly 
speculation.  The  patient  is  the  son  of  primal  force,  has  a 
divine  calling,  is  the  Lord,  suffers  for  the  whole  of  mankind, 
is  singled  out  for  distinction  by  the  Grand  Duke,  demands 
special  food,  is  going  to  marry.  All  these  delusions  are 
given  utterance  to  without  connection  and  without  emphasis, 
in  often  changing,  always  more  extraordinary  form.  Not 
infrequently  a   certain    morbid   feeling   exists   at   the   same 


198  DEMENTIA    PRECOX 

time.  "  We're  not  quite  well  yet,"  said  a  patient ;  another 
said,  "  I  used  to  have  the  delusion  that  I  was  the  King  of 
Bavaria,  or  I  was  the  Lord  God  ;  that's  just  nonsense,"  while 
a  third  declared,  "The  abuse  was  in  the  disease";  again 
others  say  that  their  sense  has  been  taken  from  them.  Or 
thev  allege,  if  they  are  asked  about  hallucinations  and 
delusions,  that  they  do  not  hear  so  much  now,  do  not  pay 
attention  to  it,  do  not  take  themselves  up  with  these  things 
an\'  more,  have  forgotten  them. 

The  really  characteristic  disorder,  however,  in  this  form  is 
iticohercucc  of  the  train  of  t/iought.  The  most  loquacious 
patients  ever  afresh  bewilder  their  hearers  by  the  confusion 
and  singularity  of  their  utterances  and  by  the  senselessness 
of  their  associations  of  ideas.  "  I  am  bird  black,"  declared  a 
patient,  another,  "  I  am  no  country,"  a  third,  "  I  am  your 
deceased  father,"  a  fourth,  "  I  believe  that  my  father  is  now 
born,"  a  fifth,  "  That  he  was  tuned  at  the  turn  of  the  year." 
The  following  are  examples  of  similar  utterances  already 
reaching  into  the  domain  of  confusion  of  thought  and  quite 
similar  to  conversations  in  dreams  :  "  I  speak  with  the  voices 
for  my  welfare  elements,"  "If  one  may  serve  after  the  right, 
the  left  must  become,"  "  In  this  custom  there  are  very  difficult 
tasks,"  "  I  still  hear  voices,  where  does  right  and  the  damage 
sits  above."  We  may,  therefore,  well  assume  that  it  is  a  case 
here  not  only  of  disorders  of  the  train  of  thought,  but  also  of 
disorders  of  expression  in  speech.  Further,  the  circumstance, 
that  silly  clang-associations  and  neologisms  frequently  come 
under  observation  is  in  favour  of  this  view  ;  many  patients 
speak  in  a  self-made  language.  The  loquacity  and  the 
richness  of  vocabulary  might  point  to  a  relationship  with 
sensory  aphasia.  Incoherence  is  usually  most  in  evidence 
when  the  patients  converse  for  some  time  and  fall  into 
excitement,  while  they  often  answer  simple  questions  quite 
correctly. 

The  patients  are  often  not  clear  about  their  position  and 
their  surroundings.  They  mistake  people,  and  call  them  by 
quite  arbitrary  names.  They  are  in  a  "  house  for  a  manure 
king  "  ;  the)'  are  "  there  because  of  an  offence  to  the  catholic 
church,"  have  "a  religious  affair,"  "  must  do  business." 

Mood  is  changeable,  often  self-conscious,  silly,  cheerful 
but  irritable  ;  it  easily  comes  to  violent  excitement  suddenly 
exploding.  The  deeper  emotional  relations  are  blunted  ;  the 
patients  do  not  trouble  themselves  about  their  surroundings, 
remain  indifferent  when  their  relatives  visit  them,  show 
neither  interest  nor  perseverance  in  work. 

Volition. — Here  also  we  invariably  meet  with   manifold 


ISSUE— TERMINAL   STATES  199 

volitional  disorders.  Some  patients  exhibit  automatic  obedi- 
ence, catalepsy,  echophenomena,  others  are  repellent, 
unmanageable,  at  times  refuse  food,  become  mute,  hide 
themselves  away  in  bed,  retire  if  any  one  approaches  them, 
force  their  way  out  senselessly,  speak  past  the  subject,  do  not 
shake  hands  ;  "  I  can  have  no  more  intercourse  with  you," 
declared  a  patient  ;  "  It's  no  use  giving  a  paw,"  said  another. 
But  most  frequent  are  mannerisms  of  all  sorts,  making  faces, 
singular  attitudes,  kneeling,  affected  movements,  rhythmical 
swaying,  running  up  and  down,  shaking  their  heads,  scratching, 
monotonous  gestures,  spitting,  licking,  smacking  with  their 
lips,  wiping,  screeching,  shrill  singing,  mincing  speech,  lisping, 
speaking  in  falsetto,  whispering,  impulsive  laughing,  obscene 
abuse,  remarkable  hairdressing  and  garments,  peculiar  spelling. 
Many  patients  are  dirty;  many  visit  the  water-closet 
innumerable  times. 

Dull  Dementia. — In  a  further  group  of  terminal  states 
the  loss  of  emotional  activity  is  more  striking  than  anything 
else,  so  that  we  may  here  speak  of  a  "  dull  dementia." 
Hallucinations  and  delusions  only  play  a  small  part  here. 
Many  patients,  it  is  true,  state  when  asked,  that  they  still 
hear  the  same  as  before,  "  filthy  things,"  "  the  wicked  enemy," 
but  they  do  not  speak  about  them  any  more  of  their  own 
accord  ;  others  "  have  forgotten  hearing  voices  "  or  only  hear 
quite  indifferent  things.  Now  and  then  the  patients  state 
that  they  are  being  influenced,  poisoned,  that  their  veins, 
their  skulls  are  burst,  their  parents  beheaded,  that  at  night 
there  is  examination  and  impropriety,  that  human  flesh  is 
given  to  them,  that  they  have  intercourse  with  the  Lord  God, 
but  such  ideas  are  not  further  elaborated  and  they  acquire 
no  determining  influence  on  the  conduct  of  the  patient.  The 
surroundings  are  as  a  rule  correctly  perceived,  though  the 
patients  may  have  little  inclination  to  account  to  themselves 
for  people  or  events  in  any  way.  Much  rather  they  live  their 
lives  dully  and  without  taking  any  interest,  do  not  trouble 
themselves  about  their  relatives,  do  not  reflect  about  their 
position,  do  not  give  utterance  either  to  wishes,  or  hopes 
or  fears. 

Mood. — At  the  same  time  the  slightly  marked  colouring 
of  the  background  of  mood  is  sometimes  more  gloomy, 
anxious,  or  lachrymose,  sometimes  more  that  of  a  vacant 
cheerfulness  with  frequent  smirking  or  laughing.  But  often 
without  recognizable  occasion  dull  indifference  is  from  time 
to  time  interrupted  by  violent  excitement  with  confused 
abuse  and  a  tendency  to  sudden  destructiveness  and  even 
to  serious  deeds  of  violence,  of  the  causes  of  which  the  patients 


2C»  DEMENTIA    PR^ECOX 

are  not  able  to  give  any  account ;  he  had  too  much  blood, 
said  one  patient.  These  states  may  recur  with  a  certain 
regularity. 

The  Volitional  Expression  of  the  patients  shows  very 
severe  disorders.  They  are  for  the  most  part  quiet,  taciturn, 
or  quite  mute,  sit  about  in  corners,  remain  standing  wherever 
they  are  pushed,  do  not  get  out  of  bed.  They  do  not  try 
to  get  away ;  they  are  prepared  to  stay  where  they  are,  till 
they  are  fetched  away ;  they  do  not  plan  to  begin  anything. 
On  the  other  hand  they  are  often  able  to  do  simple  work, 
such  as  sawing  wood,  carting,  shovelling  with  great  per- 
severance, if  they  are  put  to  it.  Rhythmical  ?Lci\ons  especially 
are  continued  by  them,  till  they  come  up  against  some 
hindrance,  at  which  they  then  stop,  till  they  are  again  set 
going.  Attitude  and  behaviour  are  sometimes  slack  and 
negligent,  sometimes  stiff  and  constrained;  movements  are 
clumsy,  uncouth,  awkward.  Marked  automatic  obedience  is 
very  frequent;  Weygandt  ^  was  still  able  to  demonstrate  it 
in  a  case  after  the  disease  had  lasted  for  fifty-four  years. 
Further  also  we  often  meet  with  negativistic  features.  The 
patients  do  not  look  up  when  they  are  spoken  to,  do  not 
answer,  stare  straight  in  front  of  them,  do  not  shake  hands, 
avoid  people,  every  now  and  then  stop  working  for  a  few 
days  and  refuse  food,  or  they  hide  away  under  the  bedclothes. 
Now  and  then  speaking  past  the  subject  is  observed,  or  quite 
unconnected  answers  are  given  ;  a  patient  replied  to  the 
usual  greeting,  "  Respect  for  religion  ought  not  to  be." 
Lastly,  impulsive  and  manneristic  actions  are  also  not  lack- 
ing, especially  in  the  ever-returning  states  of  excitement. 
The  patients  make  faces,  assume  singular  positions,  make 
monotonous  movements  for  hours  at  a  time,  play  with  their 
fingers,  strike  their  own  faces,  shake  hands  with  the  little 
finger  or  with  the  left  hand,  slide  about  on  the  floor,  run 
up  and  down,  rub  and  wipe  things,  spit,  suddenly  cry  out, 
mutter  unintelligibly  to  themselves.  They  usually  quiet 
down  again  very  quickly  and  then  sink  back  into  the  old 
dulness. 

Silly  Dementia. — Impulsiveness  and  weak  susceptibility  to 
influence  are  the  striking  characteristics  of  those  terminal 
states  which  we  class  together  as  "silly  dementia"  ;  they 
form  the  invariable  issue  of  that  clinical  type  which  we 
formerly  delimited  under  the  same  name.  Hallucinations 
and  delusions  are  frequently  entirely  lacking  here.  On  the 
other  hand  a  considerable  degree  of  weakness  of  judgment 

1  Weygandt,  Centralbl.  f.  Nervenheilk.  u.  Psychiatric,  1904,  615. 


ISSUE— TERMINAL   STATES  201 

invariably  exists.  The  patients  have  no  understanding  of 
the  kind  or  of  the  extent  of  their  disorder  or  of  their  actual 
position,  consider  themselves  well  and  able  for  work,  although 
they  perhaps  still  sometimes  suffer  from  "blocking  of  thought." 
They  wish  to  take  up  their  occupation  again,  do  not  under- 
stand why  they  are  prevented  from  doing  so.  About  their 
surroundings  and  what  occurs  in  their  neighbourhood  they 
are  quite  clear  ;  they  certainly  form  quite  erroneous  opinions 
about  details,  regard  their  fellow-patients  as  well,  treat  their 
dreams  as  real  occurrences.  They  are  able  to  occupy  them- 
selves, write  letters  and  petitions  usually  of  a  very  monotonous 
kind,  sometimes  with  verbal  identity.  Their  acquired  know- 
ledge may  be  fairly  well  preserved  ;  still  in  time  a  certain 
mental  impoverishment  always  appears,  as  the  patients  are 
not  able  to  use  what  they  have  learned.  At  every  difficulty, 
the  solution  of  which  requires  independent  thought,  they 
habitually  fail  in  a  surprising  manner. 

Mood  is  invariably  confident  and  cheerful,  more  rarely 
and  only  temporarily  depressed  and  lachrymose.  But  for 
the  most  part  the  patients  are  easily  excited  and  fall  suddenly 
into  lively  agitation  or  into  quickly  passing  outbursts  of 
rage,  sometimes  with  periodic  return.  The  lack  of  fine 
feeling  is  usually  very  striking  ;  it  makes  the  patient  wholly 
forgetful  of  the  regard  due  to  his  personal  dignity  as  well 
as  to  the  feelings  of  the  people  round  him.  In  the  same 
way  foresight  in  relation  to  the  events  of  life  and  to  the 
results  of  his  actions  and  the  ability  to  carry  out  any  plan 
consistently  are  also  lacking.  His  whole  demeanour  bears 
the  stamp  of  childish  thoughtlessness  and  stupidity.  He 
chats  without  ceremony  about  his  most  delicate  affairs,  uses 
disrespectful  expressions  about  his  parents  and  superiors, 
exposes  himself  in  the  most  incredible  way.  He  follows 
sudden  fancies  without  hesitation,  is  sometimes  immediately 
susceptible  to  influence,  sometimes  incomprehensibly  obstinate. 
He  fills  his  time  with  aimless  occupations.  "The  will  is 
present  but  I  don't  bring  it  together,"  said  a  patient.  Often 
a  certain  restlessness  exists  which  drives  the  patient. to  all 
sorts  of  foolish  actions.  He  decorates  himself  in  an  extra- 
ordinary way,  grunts,  frisks  about,  howls,  plays  with  dolls, 
smears  everything,  makes  faces,  chats  and  writes  a  great 
deal,  composes  insipid  rhymes,  speaks  in  affected  phrases, 
makes  up  singular  words. 

Manneristic  Dementia. — In  a  further  form  of  terminal 
state  which  we  shall  term  manneristic  dementia,  singular 
changes  in  volitional  actions  are  in  the  foreground  of  the 
clinical   picture.      For    the    most    part    hallucinations    and 


202  DEMENTIA    PR/ECOX 

delusions  are  still  present  here  also.  "There  are  still  always 
enouj^h  voices,"  said  a  patient.  They  torment  him  the  whole 
day,  call  out  "Filthy  fellow";  it  may  come  from  the  tele- 
phone, or  it  is  inward  speaking,  voice  annoyance.  There  are 
influences  at  night ;  there  is  foul  air  in  his  ear.  His  nature 
is  not  pure  ;  torture  is  being  carried  on  ;  it  is  known  how 
that  hajipens,  a  fatal  blow,  poisoning  of  witnesses.  Figures 
descend  from  heaven  ;  the  patient  is  being  murdered  by 
witches,  is  given  the  flesh  of  his  burnt  relatives  to  eat.  He 
is  burned  inwardly,  blown  to  pieces,  has  five  diseases,  must 
die;  his  heart  has  been  stolen.  Other  patients  are  John  the 
Cherusker,  Frederick  Barbarossa,  the  German  Emperor,  wish 
to  be  Prince  of  the  world,  a  statesman.  Many  patients  are 
quite  confused,  mistake  people,  have  "  no  more  sense  or  idea 
of  nothing."  Now  and  then  a  certain  morbid  feeling  is 
present.  The  patients  state  that  they  are  scattered  in  their 
minds,  they  cannot  remember  anything,  cannot  think  in 
their  heads,  do  not  recall  things  as  they  used  to  do.  Former 
morbid  phenomena  are  sometimes  denied  ;  the  patients  will 
have  nothing  more  to  do  with  the  voices,  "  don't  speak  any 
foreign  language  now." 

Mood  is  often  exalted,  self-conscious,  but  frequently  also 
peevish  and  irritable,  more  rarely  dull  or  lachrymose.  The 
patients  smirk  and  laugh,  but  at  times  fall  into  violent 
excitement,  break  out  into  wanton  and  obscene  abuse, 
suddenly  become  violent  and  destructive. 

Their  whole  conduct  is  dominated  by  singular  impulses, 
which  lead  to  their  carrying  out  senseless  actions,  to  diminu- 
tion, derailments,  and  in  the  end  to  the  suppression  of  their 
volitional  utterances ;  along  with  that  very  commonly 
stereotypies  develop.  The  bearing  of  the  patients  is  stiff 
and  constrained  ;  their  movements  are  affected,  theatrical, 
often  jerky  and  inelegant.  They  assume  uncomfortable 
positions,  lie  on  their  stomach,  on  their  face,  twist  themselves 
together,  hold  their  head,  press  their  hand  before  their  mouth, 
close  their  eyes,  put  out  their  lips  like  a  snout.  They  run 
round*  in  a  circle  for  hours,  beat  themselves,  impulsively 
touch  the  handle  of  the  window,  dance  about,  suddenly 
run  through  the  room,  pull  their  ears,  pull  at  their  fellow- 
patients,  devour  urine  and  faeces,  bite  their  nails  off,  pluck 
their  finger-tips  to  pieces,  sway  rhythmically  to  and  fro, 
spit  about  them,  masturbate,  smudge  things,  make  faces. 
They  adorn  themselves  in  an  extraordinary  way,  make 
singular  gestures,  affected  bows,  walk  and  eat  in  a  manneristic 
way,  shake  hands  with  their  thumb  or  two  fingers,  smack 
their  lips,  and  click   their   tongue.     Pictures   of  these   con- 


ISSUE— TERMINAL   STATES 


203 


Fig-  33-     Patient  hopping. 


ditions  are  given  in  Figs.  33  and  34,  which  represent  a 
patient  on  one  leg  hopping  about  and  another  sitting  in  a 
distorted  attitude. 

Speech. — In  the  speech 
also  of  the  patients  manner- 
ism makes  itself  felt  in  most 
manifold  ways.  The  patients 
declaim,  preach,  speak  in  a 
washed-out  way,  mawkishly, 
with  closed  teeth,  lisping,  in 
a  foreign  or  self-  invented 
speech,  with  child-like  pro- 
nunciation and  accent;  they 
give  unconnected  answers,  in- 
dulge in  silly  puns  and  clang- 
associations,  odd  expressions 
and  neologisms.  One  patient 
said  he  was  a  wicked  world- 
begetter,  another  said, "  Down 
there  is  Hell ;  she  is  called 
Miiller";  another  spoke  of 
"  Witch  -  begging-  rascal  -fur- 
nace." In  many  patients 
automatic  obedience  can  be  demonstrated  ;  but  negativistic 
features  are  much  more  frequent.     Their  capability  for  work 

is  mostly  slight,  and  is  usually 
limited  to  mechanical  activ- 
ity, copying,  knitting,  sawing 
wood,  and  that  kind  of  thing, 
even  in  the  most  favourable 
cases. 

Negativistic  Dementia. — 
As  the  last  form  of  decline 
induced  by  dementia  prae- 
cox  we  take  into  considera- 
tion negativistic  dementia, 
in  which  the  phenomena  of 
impulsive  resistance  appear  in 
a  specially  marked  way.  It 
is  nearly  related  to  the  last 
form,  since  there  just  as  here 
varied  volitional  disorders  are 
usually  combined  with  each 
other.  About  hallucinations 
or  delusions  little  is  heard 
from    the  patients,  probably 


Fig  34.     Patient  in  distorted  attitude. 


204 


DEMENTIA    PRyECOX 


for  this  reason  that  they  are  not  at  all  inclined  to  make 
statements.  Still  many  patients  abuse  the  voices  which  "  go 
against  the  man,"  close  their  ears,  complain  about  "  the 
extortion    of   the    extortioner- Bismarck."      Others   demand 


Fig.  35.     Patient  continually  holding  her  head. 

"  their  money " ;  they  have  no  one  for  a  friend,  are  first 
doctor,  the  Christ-child  in  the  manger.  The  substance  of 
their  conversation  is  mostly  confused  and  incoherent,  espe- 
cially as  soon  as  they  fall  into  excitement  ;  they  are  not  clear 
about  their  position,  and  are  without  understanding  for  the 
occurrences  in  their  surroundings. 


ISSUE— TERMINAL   STATES  205 

Mood  is  sometimes  jocular,  but  much  more  frequently 
irritable,  morose,  even  threatening ;  besides  convulsive 
laughter  furious  outbursts  of  abuse  with  a  tendency  to 
violence  occur.  At  the  same  time  the  patients  are  inaccess- 
ible, repellent,  taciturn,  or  absolutely  mute,  sometimes  for 
years ;  they  look  away  when  spoken  to,  resist  every  interfer- 
ence, refuse  food,  avoid  people,  try  to  get  away,  stand  at  one 
particular  door  in  order  to  rush  out  as  soon  as  it  is  opened. 
They  hide  their  face,  creep  under  the  bedcover,  sit  with  their 
eyes  closed,  lie  down  under  the  bed,  do  not  tolerate  any 
clothes,  stand  naked  or  in  their  shirt  beside  the  bed,  or  lie  on 
the  floor  only  wrapped  in  a  coverlet.  Many  patients  whisper 
low,  unintelligibly  to  themselves,  become  mute  as  soon  as  one 
listens  to  them;  others  in  walking  always  go  a  few  steps 
backwards  again.  If  told  to  do  anything,  they  do  not  obey, 
at  most  once  in  a  way  they  answer  with  a  slight  shake  of  the 
head.  "  We  must  not  shake  hands,"  declared  a  patient.  The 
attitude  of  the  patients  is  usually  rigid,  constrained,  some- 
times quite  odd,  and  is  for  a  long  time  monotonously  main- 
tained. An  example  of  this  is  given  in  Fig.  35  ;  the  patient 
represented  remained  continuously  in  the  same  attitude.  A 
patient  got  gangrene  from  holding  his  fist  clenched. 

Besides  the  negativistic  phenomena  there  are  invariably 
impulsive  actions,  stereotypies  and  mannerisms  as  well.  The 
patients  throw  away  their  food  or  their  shoes,  swallow  glass 
and  stones,  give  utterance  to  senseless  sounds  or  bestial  cries, 
pull  out  their  hair,  jump  about  with  great  leaps  and  suddenly 
stand  still  like  a  monument.  They  rub  their  heads  keeping 
time,  rock  with  their  body  or  with  their  foot,  make  monotonous 
movements  with  their  fingers,  shake  themselves,  stamp  on 
the  ground,  nod,  spit.  Others  lie  with  the  corner  of  the  sheet 
or  their  fingers  in  their  mouth,  assume  singular  attitudes,  shake 
hands  with  the  fourth  finger,  stir  up  their  food,  speak  lispingly 
or  in  a  stilted  manner,  invent  a  peculiar  spelling.  Here  also  the 
capability  for  work  is  always  very  severely  damaged,  though 
many  patients  can  still  be  trained  to  simple  mechanical  work. 

Prognostic  Indications. 

At  the  present  time  it  must  still  be  considered  doubtful 
how  far  the  terminal  states  here  described  really  represent  in 
individual  cases  the  last  period  of  the  development  of  the 
disease.  For  simple  weak-mindedness,  which  signifies  a  kind 
of  recovery  with  defect,  it  is  distinctly  enlightening  and  often 
confirmed  by  experience  that,  sooner  or  later,  a  fresh  exacer- 
bation of  the  disease  may  follow  and  bring  about  a  higher 
degree   and   another   form   of  dementia.      But   also   in   the 


206  DEMENTIA    PRECOX 

remaining  forms  changes  in  the  condition  are  often  possible, 
even  after  a  number  of  years,  usually  in  the  sense  of  deteriora- 
tion. That  is  especially  true  of  hallucinatory  weak-minded- 
ness. Further  we  see,  as  described  before,  paranoid  states 
not  infrequently  pass  later  into  negativistic  or  manneristic 
dementia  ;  the  same  might  be  said  of  silly  dementia  which  in 
certain  circumstances  even  after  a  decade  may  be  essentially 
changed  by  the  appearance  of  stupor  or  of  excitement. 

Drivelling,  dull  and  manneristic  dementia  appear  to  be 
variable  more  according  to  degree  than  according  to  kind. 
In  negativistic  dementia,  lastly,  so  long  as  well-marked  nega- 
tivistic stupor  exists,  the  possibility  of  considerable  improve- 
ment is  to  be  reckoned  with,  which  now  and  then  may  appear 
even  after  the  lapse  often  years.  Petren  reports  the  case  of 
a  patient  who  had  to  be  tube-fed  for  nine  years,  but  who  yet 
after  being  ill  for  eleven  years  was  so  far  restored  again  that 
he  earned  a  living  for  himself  and  his  family  as  a  tailor  and 
only  showed  still  a  certain  irritability.  It  appears  accordingly 
that  in  stupor  there  are  fundamental  changes  which  still  after 
a  very  long  time  are  capable  of  retrogression.  But  it  is  very 
difficult  in  individual  cases  to  decide  whether  such  a  possibility 
still  exists  or  not.  It  appears  that  in  the  cases  which  finally 
have  become  incurable,  the  severity  and  especially  also  the 
promptness  of  the  negativistic  reaction  to  interference  relax 
considerably.  This  suggests  that  there  is  a  loosening  of  the 
inner  harmony  between  impressions,  impulses  and  volitional 
actions  as  we  formerly  saw  it  as  a  fundamental  disorder  in 
dementia  praecox. 

In  the  remaining  forms  also  of  the  terminal  states  the 
point  of  time  is  difficult  to  determine  from  which  onward  the 
appearance  of  considerable  improvement  can  no  longer  be 
expected.  On  the  whole  the  prospects  will  be  the  more 
unfavourable  the  more  those  peculiarities  are  developed, 
which  we.  see  in  the  foreground  in  the  multitude  of  cases 
finally  uncured.  Among  them  there  is  especially  the  loss  of 
emotional  activity  which  characterizes  the  most  severe  forms 
of  the  disease,  those  that  issue  in  dull  dementia  ;  with  it  the 
connecting  link  falls  away  which  unites  rational  action  to 
perception  and  thought.  Furthermore  the  development  of 
fixed  mannerisms  and  stereotyped  movements  is  apparently 
to  be  regarded  as  an  unfavourable  sign  ;  they  are  a  sign  that 
the  influence  of  healthy  volitional  action  and  inhibition  on 
activity  is  no  longer  strong  enough  to  suppress  side-impulses 
and  the  tendency  to  repetition.  Of  specially  bad  significance 
is  the  appearance  of  simple  rhythmical  movements  ;  they 
seem  only  then  to  occur  when  through   very  deep-reaching 


ISSUE— TERMINAL   STATES  207 

destruction  of  the  volitional  apparatus  lower  ancestral  motor 
mechanisms  acquire  a  certain  independence.  Lastly,  the 
states  of  excitement  and  moodiness  occurring  periodically 
and  abruptly  are  probably  also  of  evil  significance,  as  they 
very  frequently  make  their  appearance  in  the  incurable 
terminal  states.  These  also  might  indicate  that  the  equili- 
brating mechanisms  were  disordered,  which  otherwise  make 
the  psychic  life  to  some  extent  independent  of  the  fluctuations 
of  bodily  conditions. 

We  come  therefore  to  the  conclusion  that  the  onset  of 
incurable  terminal  states  is  announced  chiefly  by  those 
disorders  which  signify  the  loss  of  mastery  over  volitional 
action,  be  it  that  the  mainsprings  of  volition  are  broken,  be  it 
that  the  mechanisms  are  destroyed  which  make  systematic 
co-operation  of  individual  volitional  actions  possible.  I 
would  ascribe  much  less  importance  to  pure  disorders  of 
intellect.  They  appear  in  general  to  be  further  removed 
froKi  the  point  of  attack  of  the  morbid  process,  and  therefore 
not  so  soon  to  signify  incurable  phenomena  of  decay.  Not 
only  may  hallucinations  and  nonsensical  delusions  be  again 
completely  lost,  but  also  incoherence  of  the  train  of  thought, 
and  indeed  even  marked  confusion  of  speech.  Only  then 
when  with  continuance  of  these  disorders  emotional  activity 
also  gradually  disappears,  is  one  obliged  to  consider  the 
hope  of  equilibrium  being  restored  as  very  slight. 

The  prognosis  of  individual  cases  is  made  essentially 
more  difficult  by  the  circumstance  that  it  is  not  always  easy 
to  obtain  absolute  certainty  about  the  existence  of  the  above- 
mentioned  symptoms.  Indifference  towards  occurrences  in 
the  surroundings  may  also  be  simulated  by  negativism  or 
by  stupor.  Only  then  when  the  patients,  in  spite  of  complete 
understanding  and  without  a  symptom  of  negativism,  show 
no  further  interest  at  all  in  their  fellow  -  patients,  their 
relatives  or  their  occupation,  and  accept  quite  indifferently 
threats  or  contradiction  in  regard  to  their  delusions,  may  we 
conclude  that  there  is  a  real  annihilation  of  emotional 
activity.  In  the  same  way  only  the  stereotypies  which  have 
been  retained  for  long  and  have  become  quite  rigid,  and 
lastly,  only  those  states  of  moodiness  and  excitement,  which 
without  external  cause  return  abruptly  with  approximate 
regularity,  and  after  very  short  duration  disappear  again  in 
the  same  way,  are  to  be  taken  into  account  in  judging  of  the 
prospect  of  recovery. 

Frequently  not  without  significance  also  for  judging  the 
condition  is  the  behaviour  of  the  body  weight.  As  the  rising 
of  this  in  general  signifies  a  disappearance  of  acute  morbid 


2o8  DEMENTIA   PRvECOX 

phenomena,  it  may  announce  either  the  beginning  of  im- 
provement or,  on  the  other  hand,  the  development  of  a  final 
state  of  weakness.  The  decision  between  these  two  possi- 
bilities is  furnished  by  observation  of  the  psychic  behaviour. 
If  the  disappearance  of  the  disorders  which  hitherto  have 
been  dominant  is  combined  with  a  return  of  emotional 
activity,  accessibility,  interest  in  the  surroundings  and  the 
relatives,  and  need  for  employment,  a  favourable  turn  of  the 
course  of  the  disease  may  be  reckoned  on.  But  if  the  patients 
in  spite  of  increase  of  body  weight  remain  incoherent,  unin- 
terested, silly,  manneristic,  inaccessible,  the  probability  is 
very  great  that  the  disease  has  reached  a  final  and  unfavour- 
able conclusion.  Whether  the  loss  of  the  psychic  pupillary 
reaction  is  of  prognostic  significance  in  the  individual  case, 
must  in  the  meantime  still  remain  undecided.  At  any  rate 
there  are  demented  patients  enough  in  whom  it  is  preserved, 
while  in  other  cases  it  is  already  absent  in  the  beginning  of 
the  disease.  At  the  same  time  its  disappearance  seems  tp  be 
considerably  more  frequent  in  the  terminal  states.  Zablocka 
states  that  difference  in  the  pupils  also  seems  to  have  a  certain 
unfavourable  significance. 

Lastly,  if  we  put  before  ourselves  the  question  by  what 
circumstances  the  issue  of  the  disease  is  determined,  obviously 
the  clinical  form  is  in  the  first  degree  decisive.  Racke 
thought  the  prospects  of  recovery  by  far  the  most  favourable 
in  what  he  delinwted  as  the  "subacute  paranoid  forms,"  con- 
siderably more  unfavourable  in  the  "  depressive,"  still  worse 
in  the  "  excited-confused  "  and  in  the  "  stuporous  "  forms.  If 
we  go  back  to  our  classification,  we  saw  formerly  that  periods 
of  improvement  lasting  a  considerable  time  are  principally 
observed  in  the  excited  and  the  catatonic  forms,  therefore  by 
preference  in  the  forms  which  have  an  acute  commencement 
and  course,  while  the  simple,  silly  and  paranoid  forms  of 
dementia  prsecox  which  usually  begin  insidiously  offer  far  less 
prospect  of  material  remissions  of  the  morbid  phenomena. 

With  regard  to  t\\Q  final  issue  the  relations  are  somewhat 
different.  Slighter  degrees  of  psychic  decline  are,  it  is  true, 
likewise  fairly  frequent  in  the  excited  forms,  but  are  also 
often  the  issue  of  depressive  forms  and  of  simple  progressive 
dementia  ;  further  we  may  perhaps  also  regard  hallucinatory 
weak-mindedness,  and  at  least  a  part  of  the  paranoid  states  of 
weak-mindedness,  as  relatively  favourable  issues.  On  the 
other  hand  the  catatonic  forms,  silly  dementia,  and  the  first 
group  of  the  paranoid  forms  usually  have  with  greater  fre- 
quency profound  psychic  weakness  as  a  result.  Closer  rela- 
tions between  the  clinical  forms  and  definite  terminal  states 


ISSUE— TERMINAL   STATES  209 

can  scarcely  be  demonstrated.  Yet  dull  dementia  appears  to 
be  developed  most  frequently  from  silly,  simple  depressive 
and  excited  forms,  while  negativistic  and  manneristic  states 
of  weak-mindedness  constitute  the  issue  specially  of  the  cata- 
tonic, the  depressive-stuporous  and  certain  paranoid  forms. 
Those  forms  which  begin  with  silliness  are  also  characterized 
by  it  in  their  terminal  states  ;  incoherence  appears  to  char- 
acterize by  preference  the  issue  of  the  states  of  excitement. 
Lastly,  hallucinatory  and  paranoid  weak-mindedness  comes 
essentially  under  observation  as  the  conclusion  of  paranoid 
forms. 

According  to  Zablocka's  statements  the  appearance  of 
mutism  of  long  duration  and  of  stereotypies  indicates  the 
probability  of  a  more  profound  dementia,  and  the  same  may 
be  said  of  an  insidious  commencement  of  the  disease.  On 
the  other  hand  Bleuler  states  that  cases  with  considerable 
improvement  after  the  first  attack  of  the  disease  seldom 
become  profoundly  demented  later.  His  further  statement 
that  acute  forms  show  a  greater  tendency  to  very  severe 
terminal  states  I  can  thoroughly  confirm  for  catatonic  forms, 
but  for  states  of  excitement  only,  with  the  limitation  that 
here  besides  the  frequent  dull,  manneristic  or  drivelling 
dementia,  the  issue  in  simple  weak-mindedness  is  also  very 
often  observed. 

Of  further  influences,  which  may  acquire  significance  for 
the  issue  of  the  disease,  there  might  be  mentioned  predis- 
position^ while  external  causes  in  any  case  play  no  decisive 
part.  Bleuler  considers  those  cases  more  unfavourable  in 
which  from  childhood  up,  abnormal  qualities  have  appeared, 
and  Zablocka  also  thinks  that  there  is  in  them  a  stronger 
tendency  to  profound  dementia.  That  becomes  intelligible, 
if  one  assumes  that  in  such  cases  through  an  inferior  dis- 
position either  there  exists  a  lesser  power  of  resistance  to 
the  morbid  process,  or  the  morbid  process  itself,  develop- 
ing insidiously  from  childhood,  has  already  generated  those 
abnormalities.  The  last  view  would  be  supported  by  Bleuler's 
statement  that  inherited  weakness  does  not  exercise  any 
influence  on  the  prognosis.  On  the  other  hand,  Mattauschek 
reports  that  dementia  praecox  has  a  more  unfavourable  course 
among  Slavs  and  Jews  than  among  Germans. 

The  Age  of  the  patients  has  a  decided  influence  on  the 
course  of  the  disease.  The  forms  which  begin  in  the  years 
of  development  are  by  preference  states  of  excitement, 
especially  those  with  a  periodic  course,  then  simple  depressive 
forms,  and  certainly  also  insidious  dementia  (dementia 
simplex),  morbid   states   which  in  general   tend  to  have  a 

O 


210  DEMENTIA    PRyECOX 

milder  course.  Somewhat  later  silly  dementia  and  the 
catatonic  forms  have  their  greatest  frequency,  that  is,  forms 
which  are  decidedly  to  be  regarded  as  severe.  Still  later, 
depression  with  delusions  is  developed,  likewise  a  form  with 
an  unfavourable  course  predominating.  Lastly,  in  definitely 
advanced  age  the  paranoid  forms  appear,  which  on  the  one 
hand  lead  not  so  very  frequently  to  the  most  severe  forms 
of  psychic  weakness,  but  on  the  other  hand  show  very  little 
tendency  to  essential  improvement  of  the  morbid  state  when 
it  is  once  developed.  It  could,  therefore,  be  approximately 
said  that  here  with  advancing  age  the  ability  to  restore  the 
equilibrium  and  repair  the  damage  generated  by  the  disease 
gradually  diminishes,  but  that  at  the  same  time  the  work  of 
destruction  appears  to  spread  less  deeply. 

Sex. — There  appear  also  to  be  certain  relations  between 
sex  and  the  form  of  the  disease.  Men  have  a  somewhat 
larger  share  in  the  unfavourable  form  of  silly  dementia  ; 
women  on  the  other  hand  have  a  greater  tendency  to  paranoid 
forms,  a  circumstance  which  might,  generally  speaking,  be 
connected  with  the  greater  frequency  of  paranoid  morbid 
states  in  the  period  of  involution  in  the  female.  Women  are 
in  a  still  greater  majority  in  the  states  of  excitement  running 
a  periodic  course,  but  here  there  are  not  nearly  enough 
statistics  to  hand  ;  otherwise  one  might  in  these  forms  be- 
ginning in  youth  think  of  the  influence  of  the  so  strongly 
marked  tendency  in  woman  to  a  periodic  course  of  normal 
as  well  as  of  morbid  processes. 

The  Time  in  which  the  development  of  an  incurable 
terminal  state  is  accomplished  naturally  fluctuates  within 
very  wide  limits.  For  one  thing  the  exact  commencement 
of  the  morbid  phenomena  can  often  enough  only  be  deter- 
mined with  great  difficulty,  as  all  sorts  of  insidious  changes 
have  already  for  years  been  developing  imperceptibly.  But 
then,  as  already  detailed,  considerable  improvement  lasting 
a  long  time  may  make  the  course  of  the  disease  extraordin- 
arily slow.  Lastly,  it  is  often  scarcely  possible  to  mark 
the  point  of  time,  even  merely  approximately,  at  which  the 
final  stage  of  dementia  is  reached.  Strictly  speaking,  one 
will  never  be  quite  certain  here,  as  probably  changes  in  the 
condition  may  still  appear,  and  certainly  for  the  most 
part  in  a  downward  direction.  In  spite  of  these  difficulties 
so  much  may  perhaps  be  said  that  as  a  rule,  if  no  essential 
improvement  intervenes,  in  at  most  two  or  three  years 
after  the  appearance  of  the  more  striking  morbid  phenomena 
a  state  of  weak-mindedness  will  be  developed,  which  usually 
changes  only  slowly  and  insignificantly.     But  often  enough 


ISSUE— TERMINAL   STATES  211 

the  unmistakable  symptoms  of  dementia  appear  already 
within  the  first  year,  indeed  even  after  a  few  months,  though 
here  a  prodromal  period  of  considerable  length  can  never 
be  excluded.  Albrecht  states  that  of  his  hebephrenic  patients 
27  per  cent.,  of  his  catatonics  19  per  cent.,  reached  their 
terminal  state  within  the  first  year. 

Mortality. — Life  is  threatened  only  very  slightly  by 
dementia  praicox.  Kerner  on  the  ground  of  researches  in 
the  institution  at  Rheinau  comes  to  the  conclusion  that  the 
mortality  of  patients  with  dementia  praecox  is  somewhat 
greater  than  that  of  the  healthy  population  of  the  same  age. 
Here  account  must  be  taken  of  the  fact  that  the  patients 
in  the  institution  on  the  one  hand  are  in  high  degree  pro- 
tected from  many  of  the  injuries  of  life,  struggle  for  existence, 
alcoholism,  syphilis,  accidents,  and  lead  a  quiet  life  constantly 
supervised  by  medical  skill,  but  that,  on  the  other  hand,  the 
confinement,  with  the  small  space  which  it  affords  for  exer 
cise,  considerably  lowers  the  tonicity  of  the  body,  and  that 
the  crowding  of  people  together  favours  the  development  of 
tuberculosis.  But  of  much  greater  importance  is  the  circum- 
stance, that  by  the  psychic  disease  itself  conditions  are 
created  which  are  fitted  to  increase  the  mortality.  Dull  and 
negativistic  dementia,  but  especially  stuporous  states,  which 
often  last  for  years,  bring  about  more  or  less  complete  bodily 
inactivity  with  depression  of  the  work  of  lungs  and  heart 
and  of  the  whole  metabolism  ;  in  addition  to  that  the 
patients  by  hiding  away  under  the  bedcover  and  obstinate 
resistance  forcibly  shut  themselves  off  from  the  enjoyment 
of  fresh  air  and  often  also  take  food  very  irregularly  or 
of  an  unsuitable  kind,  or  they  may  even  for  a  long  time 
have  to  be  tube-fed.  Other  dangers  threaten  owing  to  the 
impossibility  of  treating  suitably,  because  of  restlessness  or 
obstinacy  on  the  part  of  the  patients,  bodily  suffering  caused 
by  chance  injuries  in  states  of  excitement  or  by  damage 
which  the  patients  infliet  on  themselves.  The  most  frightful 
mutilations  of  themselves  carried  out  often  with  incredible 
rapidity  and  energy,  tearing  out  of  eyes  or  tongue,  self-castra- 
tion, are  occasionally  observed  in-  our  patients.  Also  unex- 
pected suicide,  especially  in  the  first  period  of  the  malady,  is 
not  infrequent,  and  occurs  sometimes  without  any  recognizable 
cause  also  in  patients  who  for  long  have  been  weak-minded 
and  apparently  quiet. 

But  lastly,  in  certain  circumstances  the  morbid  process  as 
such  may  also  lead  to  death.  Occasionally,  though  seldom, 
it  is  observed  that  in  severe  states  of  excitement  of  long 
duration    a   steadily   progressive   loss  of  strength  gradually 


212  DEMENTIA   PRECOX 

makes  its  appearance,  which  continues  even  when  the 
patients  become  quieter  and  take  abundant  nourishment. 
Finally  death  ensues  with  extreme  cardiac  weakness  and 
great  sinking  of  the  temperature  without  the  autopsy 
showing  any  perceptible  organic  disease  at  all.  It  is 
customary  to  speak  here  of  exhaustion  which  is  thought  to 
be  caused  by  the  restlessness,  the  profound  disorder  of  sleep 
and  the  irregular  taking  of  nourishment.  But  as  further  on 
we  must  assume  a  cause  which  generates  all  those  disorders, 
the  possibility  must  also  be  reckoned  with,  that  the  same 
cause  directly  threatens  life  perhaps  by  far-reaching  injury  to 
the  body  mechanisms.  Less  uncertain  is  the  causation  of 
death  by  the  morbid  process  itself  in  those  somewhat 
frequent  cases,  in  which  the  death  of  the  patients  results  at 
the  height  of  severe  excitement,  accompanied  by  phenomena 
of  cerebral  irritation  with  convulsions  or  paralyses,  sometimes 
with  almost  continuous  seizures.  According  to  the  investiga- 
tions of  Reichhardt  it  has  become  probable  that  here  we 
have  to  do  with  an  acute  "cerebral  oedema,"  with  rapid 
changes  of  the  brain  which  cause  an  enlargement  of  volume 
and  therewith  the  appearance  of  fatal  cerebral  pressure. 
Now  and  then  cases  of  sudden  death  ^  occur  in  stupor  or  in 
the  terminal  states,  sometimes  in  a  catatonic  attack,  some- 
times without  any  striking  phenomena  Fankhauser  found 
in  some  cases  of  the  last  kind  status  lymphaticus. 

^  Giannelli,  Rivista  di  patologia  nervosa  e  mentale  xiii.  4. 


CHAPTER  VIII. 

MORBID  ANATOMY. 

The  morbid  anatomy  ^  of  dementia  praecox  does  not  show 
macroscopically  any  striking  changes  of  the  cranial  contents  ; 
only  occasional  thickening  and  oedema  of  the  pia  are  re- 
ported, the  latter  evidently  a  result  of  agonal  processes.  On 
the  other  hand,  it  has  been  shown  that  in  the  cortex  we  have 
to  do  with  severe  and  widespread  disease  of  the  nerve-tissue. 
In  some  cases  which  succumbed  in  a  condition  of  acute 
delirium  and  which  are  classed  by  him  as  catatonia, 
Alzheimer  has  described  deep-spreading  changes  in  the 
cortical  cells,  especially  in  the  deep  layers.  The  nuclei  are 
very  much  swollen,  the  nuclear  membrane  greatly  wrinkled, 
the  body  of  the  cell  considerably  shrunk  with  a  tendency  to 
disintegration.  Similar  findings  have  often  been  brought 
forward  since  then,  also  in  cases  which  after  psychic  decline 
of  considerable  duration  had  succumbed  to  other  diseases. 
Nissl  invariably  saw  widespread  cellular  disease,  which  had 
led  to  considerable  loss  without,  however,  causing  that 
extreme  distortion  and  shrinking  of  the  cortex  which  we 
have  seen  in  paralysis.  In  the  old  cases  which  have  reached 
a  termination,  Alzheimer  found  widespread  changes  in  the 
cells  which  must  be  regarded  as  the  terminal  state  of  grave 
disease  which  has  run  its  course,  in  particular  sclerotic  forms. 
Very  frequently  deposits  of  lipoid  products  of  decomposition 
were  found  in  the  various  tissue-cells,  even  already  in  quite 
young  persons.  With  striking  frequency  were  groups  of 
nerve-cells  observed,  in  which  the  basal  processes  appeared 
to  be  swollen  and  deformed  by  accumulation  of  fat.  Lastly 
diffuse  loss  of  cortical  cells  could  also  be  established.  All 
these  most  severe  morbid  residua  could  be  demonstrated  in 
marked  predominance  in  the  second  and  third  cortical  layers. 
Wada  states  likewise  that  the  large  pyramidal  cells  are 
comparatively  less  affected.     Sioli  was  able  to  demonstrate 

^Alzheimer,  Centralbl.  f.  Nervenheilk. ,  1900,296;  De  Buck  et  Deroubaix, 
Le  nevraxe  vii.  2,  163;  Zalplachta,  Revista  stintelor  medicale  1906,  7-10; 
Agostini,  SuU'  analomia  patologica  dei  centri  nervesi  della  demenza  primitiva., 
1907;  Goldstein,  Archiv,  f.  Psychiatric  xlvi.  1062;  Wada,  Obersteiners  Arbeiten 
xviii.  313. 


214  DEMENTIA    PRECOX 

in  connection  with  the  destruction  of  the  cells  a  great 
accumulation  of  lipoid  disintegrated  material  in  the  cortex, 
in  the  tissue  and  specially  round  the  vessels.  He  often 
found  the  fibrils  still  well  preserved  ;  Moriyasu  often  found 
them  disintegrated.  Wada  reports  that  the  extra-cellular 
fibrils  are  profoundly  changed,  and  Goldstein  asserts  that  in 
particular  the  coarser  fibrils  are  damaged. 

The  ^//rt  has  a  great  share  in  the  morbid  processes.  In 
the  acute  cases  Alzheimer  saw  the  presence  of  am(jeboid 
hyperplasia  of  neuroglia,  accumulation  of  glia  cells  round 
the  nerve-cells  and  morbid  new  formation  of  fibres,  which 
"embraced"  the  cells  in  a  peculiar  way.  Nissl  observed 
especially  in  the  deeper  cortical  layers  numerous  large  glia 
cells  undergoing  involution,  of  a  kind  that  occurs  in  normal 
circumstances  only  on  the  margin  of  the  cortex.  Specially 
striking  further  was  the  fact  that  everywhere  glia  cells 
were  found  with  the  bodies  of  the  cell  scarcely  coloured, 
and  with  vesicular,  peculiarly  pale,  very  large  nuclei,  which 
often  seemed  to  be  closely  applied  to,  or  indeed  to  have 
penetrated  into,  the  diseased  nerve-cells,  mostly  at  the  base 
like  the  ordinary  satellite  nuclei,  but  also  in  other  places. 
These  structures  could  be  demonstrated  with  greatest  ease  in 
the  inner  zone  of  the  medullary  border  layer.  According  to 
Sioli  the  glia  cells  in  the  first  cortical  layer,  then  those  in  the 
deep  layer  of  the  cortex  and  in  the  medulla  exhibit  a  strong 
tendency  to  morbid  formation  of  fibres  and  to  the  protoplasm 
becoming  coarse;  in  the  medulla  amoeboid  j^lia  cells  were 
found  in  abundance.  Eisath  likewise  saw  increased  fibre- 
formation,  dark  staining  of  the  glia  nuclei,  and  in  the  deeper 
layers  increase  of  the  granular  substance  of  the  glia,  a  few 
sickle-shaped  satellite  cells  with  disintegration  of  pigment, 
in  the  medulla  degenerated,  atrophic  glia  cells  and  sometimes 
increase,  sometimes  decrease,  of  fibre-formation. 

The  niedullary  fibres  appear  according  to  the  findings  of 
Goldstein,  De  Buck  and  Deroubaix  somewhat  thinned 
especially  in  the  supraradial  network  ;  Goldstein,  Agostini, 
Gonzales,  Moriyasu,  Klippel,  and  Lhermitte  describe  slight 
loss  of  fibres  in  the  tracts  and  changes  in  the  anterior  horn 
cells  of  the  spinal  medulla.  By  some  investigators,  Obregia, 
Klippel  and  Lhermitte,  Doutrebente  and  Marchand  changes 
in  the  vessels  were  also  found,  new  formation  of  vessels, 
proliferation  of  vascular  cells.  As  the  vessels,  however, 
as  a  rule,  have  no  share  in  the  morbid  process,  we  have  here 
probably  to  do  with  chance  side-findings  caused  possibly  by 
age,  alcoholism  or  syphilis.  Doutrebente  and  Marchand  saw 
numerous  nerve-cells  in  the  embryonic  stage  of  development; 


MORBID    ANATOMY 


215 


Agostini  also  reports  some  traces  of  arrested  development 
and  residua  of  childish  diseases.  Mondio  found  in  six  cases 
anomalies  in  the  convolutions,  which  he  regards  as  signs  of 
degeneration.    Schroder  from  the  same  point  of  view  describes 


Fig.   36.       Nerve-cells  surrounded  by  glia  nuclei. 

in  one  case  displacement  of  Purkinje  cells  and  double  nuclei, 
and  also  syncytial  formations  in  the  pyramidal  cells  of  the 
cerebral  cortex. 

The  accompanying  figures  represent  some  of  the  most 
important  findings  in  dementia  praicox.  The  first  two  figures 
represent  acute  changes.  In  Fig.  36  a  number  of  nerve-cells 
from  the  deep  layers  of  the  cortex  are  reproduced,  which  are 
surrounded   as   thickly  as  possible   by  numerous  glia   cells 


2l6 


DEMENTIA    PR^ECOX 


recognizable  by  their  dark  nuclei,  some  of  which  have  very 
much  enlarged  protoplasmic  bodies.  The  distribution  of 
decomposition  products  is  represented  in  Fig.  37,  \yhich  is 
taken  from  the  cortex  of  a  stuporous  patient  who  died  sud- 
denly in  a  seizure.     Two  glia  nuclei  (^)  are  seen,  round  which 


Fig-  37-   Fibrinoid  granules  in  glia  cells. 

are  grouped  radiating  chains  of  fine  granules  ;  these  are 
fibrinoid  granules  which  have  accumulated  in  the  far-branch- 
ing protoplasmic  bodies  of  the  glia  cells  which  are  otherwise 
not  recognizable  here.  The  lower  glia  nucleus  lies  on  the 
nucleus  of  a  nerve-cell  («)  still  partially  visible ;  in  the  neigh- 
bourhood of  the  upper  nucleus  also  there  is  a  nerve-cell  («). 

The  chronic  changes  in  the  nerve  cells  are  reproduced  in 
the  two  following  figures.  In  Fig.  38  three  nerve-cells  from 
the  upper  part  of  the  third  layer  of  a  healthy  frontal  lobe  are 
represented  ;  beside  these  there  are  two  normal  glia  nuclei. 
In  contrast  to  that  three  cells  from  the  corresponding  part  of 
the  cortex  of  a  patient  who  died  after  long  duration  of 
dementia  pnx'cox  in  his  twenty-fifth  year  are  seen  in  Fig.  39. 
The  narrowed  shrunken  cells  with  dark,  long-drawn-out 
nuclei  and  deeply  stained   processes  exhibit  the  picture  of 


MORBID   ANATOMY 


217 


cell-sclerosis  ;  the  tissue  arranged  as  a  network  contains  lipoid 
products  of  disintegration.  Of  the  glia  nuclei  lying  beside 
them  one  is  unusually  large  ;  the  other  two  are  small  and 


Fig.  38.   Normal  nerve-cells  with  glia  nuclei. 

darkly  stained  (pyknotic).  In  Figs.  40  and  41  also  there  are 
healthy  and  diseased  nerve-cells  placed  in  contrast.  In  two 
of  the  healthy  cells  and  in  one  of  the  two  glia  cells  lying 
between  them  there  are  only  a  few  fine  lipoid  droplets.  The 
drawings  are  from  the  third  layer  of  the  frontal  lobes  of  a 
woman  thirty-seven  years  of  age  who  was  mentally  sound. 


Fig.  39.  Sclerotic  nerve-cells  in  dementia  prsecox. 


In  contrast  we  see  the  diseased  cells,  changed  in  the  highest 
degree  ;  they  were  taken  from  the  cortex  of  a  man  twenty- 
three  years  of  age  who  had  suffered  for  five  years  from 
dementia  praecox.  In  consequence  of  the  distortion  of  the 
cortical  structure  caused  by  the  morbid  process  some  of  the 
cells  are  obliquely  placed  ;  their  nuclei  are  shrunken  and 
elongated,  their  processes  are  recognizable  for  a  long  way. 
But  above  everything  one  sees  the  shapeless,  turgid  body  of 
the  cells  and  also  the  processes  completely  filled  with  lipoid 


2i8  DEMENTIA    PR.CCOX 

products  of  disintegration.  Here  also  there  meet  us  two 
unusually  large  glia- nuclei  along  with  a  small  dark  one;  the 
cell-bodies  of  these,  which  otherwise  are  not  visible,  show 
numerous  lipoid  granules. 

As  in  the  clinical  picture  of  the  disease  there  are  appar- 
ently also  in  the  anatomical  findings  two  different  groups  of 
processes,  first  the  morbid  disorders  caused  directly  by  the 
disease,  and  second  the  losses  remaining  as  a  consequence. 
To  the  first  belong  the  changes  in  the  cells,  the  formation  of 
products  of  disintegration,  the  hyperplasia  of  glia,  especially  the 


I* 


i^j^ 


Fig.  40.   Healthy  nerve-cells.  Fig.  41.  Nerve-cells  diseased  in  high  degree  filled 

with  lipoid  products  of  disintegration. 

appearance  of  amceboid  glia  cells ;  to  the  second  the  destruc- 
tion of  cells  and  fibres,  the  necrotic  and  involutionary  pheno- 
mena in  nerve-tissue  and  glia,  the  deposition  of  fat  and 
pigment.  According  to  whether  it  is  a  recent  case  relatively, 
an  acute  relapse  of  the  disease,  or  an  old  case  in  the  terminal 
state  when  the  disease  has  long  since  run  its  course,  the  com- 
bination of  anatomical  changes  will  be  different. 

It  has  been  already  mentioned  that  the  loss  is  for  the 
most  part  to  be  found  in  the  second  and  third  cortical  layers. 
Whether  it  extends  over  wide  cortical  areas  to  the  same 
degree,  remains  still  to  be  investigated  ;  by  some  investigators, 
Mondio,  Zalplachta,  Agostini,  De  Buck  and  Deroubaix, 
Dunton,  Wada,  it  is  stated  that  it  involves  the  frontal  lobes 
and  the  area  of  the  central  convolutions,  also  the  temporal 
lobes  to  a  greater  degree  than  the  occipital  cortex.  Klippel 
and  Lhermitte  report  atrophic  changes  also  in  the  cere- 
bellum. 

In  the  remaining  organs  of  the  body  in  general  only  the 
findings  resulting   from  the  chance  cause  of  death  can  be 


MORBID    ANATOMY  219 

found.  Dide,  who  looked  for  changes  in  the  sexual  glands, 
found  these  healthy,  but  on  the  other  hand  often  saw  fatty 
degeneration  of  the  liver.  Benigni  and  Zilocchi  describe  two 
cases  with  diffuse  fatty  degeneration  in  the  liver,  kidneys, 
heart,  vessels,  thyroid  gland,  and  hypophysis.  It  must  in  the 
meantime  remain  undecided  whether  such  findings  have  any 
further  significance. 

Relation  of  Morbid  Anatomy  to  the  Clinical  Picture. — 
If  we  now  make  the  attempt  to  consider  the  relation  of  the 
anatomical  findings  which  hitherto  have  been  got,  to  the 
clinical  picture  of  the  disease,  there  are  two  points  which 
might  be  considered  significant,  the  distribution  of  the  morbid 
changes  on  the  surface  of  the  cortex,  and  the  share  of  the 
different  layers  of  the  cortex.  If  it  should  be  confirmed  that 
the  disease  attacks  by  preference  the  frontal  areas  of  the 
brain,  the  central  convolutions  and  the  temporal  lobes,  this 
distribution  would  in  a  certain  measure  agree  with  our  present 
views  about  the  site  of  the  psychic  mechanisms  which  are 
principally  injured  by  the  disease.  On  various  grounds  it  is 
easy  to  believe  that  the  frontal  cortex,  which  is  specially  well 
developed  in  man,  stands  in  closer  relation  to  his  higher 
intellectual  abilities,  and  these  are  the  faculties  which  in  our 
patients  invariably  suffer  profound  loss  in  contrast  to  memory 
and  acquired  capabilities.  The  manifold  volitional  and  motor 
disorders,  which  extend  partly  to  the  harmonious  working  of 
the  muscles,  will  make  us  think  of  finer  disorders  in  the 
neighbourhood  of  the  precentral  convolution.  As  it  does  not 
go  so  far  as  paralyses  or  to  genuine  apractic  disorders,  and 
there  are  only  indications  occasionally  of  motor-aphasic 
disorders,  we  may  assume,  although  as  yet  no  investigations 
on  the  subject  are  to  hand,  that  the  actual  motor  discharging- 
stations  are  not  attacked  by  the  destructive  process.  On  the 
other  hand  the  peculiar  speech  disorders  resembling  sensory 
aphasia  and  the  auditory  hallucinations,  which  play  such  a 
large  part,  probably  point  to  the  temporal  lobe  being  involved. 
Here  also,  however,  there  is  no  true  auditory  aphasia,  but 
only  a  weakening  of  the  regulating  influence  of  clang-associa- 
tion on  the  movements  of  speech  expression,  perhaps  also 
a  loosening  of  the  connection  between  the  former  and  con- 
ceptions ;  we  must,  therefore,  imagine  that  the  disorder  is 
essentially  more  complicated  and  less  circumscribed  than  in 
sensory  aphasia.  The  auditory  hallucinations,  which  exhibit 
predominantly  speech  content,  we  must  probably  interpret  as 
irritative  phenomena  in  the  temporal  lobe ;  it  might  not  be 
due  to  chance  that  we  invariably  observe  them  along  with 
confusion   of  speech   and  neologisms.      The  phenomena  of 


220  DEMENTIA    PRECOX 

hallucinatory  repetition  and  hearing  of  thought  point  to  the 
relations  between  ideas  and  sensory  areas  being  attacked  by 
peculiar  disorders. 

As  the  significance  of  the  cortical  layers  is  at  present  still 
almost  wholly  unknown,  it  will  scarcely  be  possible  to  set  up 
hypotheses  with  regard  to  the  influence  of  the  site  of  the 
morbid  processes  in  definite  layers,  although  it  is  certainly 
not  indifferent  for  the  form  of  the  disease.  According  to  the 
extended  experience  of  Alzheimer  we  may  assume  that  the 
permanent  loss  of  nerve-tissue  capable  of  work  concerns 
preferably  the  second  and  the  third  layer  of  the  cortex, 
therefore  the  smaller  nerve-cells,  though  in  the  acute  periods 
of  the  malady  a  severer  attack  of  the  deeper  layers  is  simulated 
by  the  proliferation  of  glia  which  is  there  specially  conspicuous. 
On  the  other  hand  the  first  terminal  stations  of  the  paths 
radiating  from  the  sense-organs  into  the  cortex  and  the  large 
motor  cells,  in  which  we  locate  the  origin  of  the  pyra- 
midal tracts  which  make  their  way  to  the  spinal  marrow,  both 
lie  in  the  depth  of  the  cortex  the  structure  of  which,  moreover, 
still  most  resembles  that  of  the  cortex  of  the  lower  animals. 
In  these  layers,  therefore,  will  the  processes  presumably  take 
place,  which  correspond,  on  the  one  hand  to  the  appearance 
of  a  sensory  perception,  on  the  other  hand  to  the  discharge  of 
a  motor  impulse,  or  are  immediately  connected  with  these. 

In  opposition  to  this  we  may  ascribe  to  the  upper  small- 
celled  layers  such  activities  as  are  peculiar  to  the  higher 
psychic  stages  of  development  since  they  reach  their  highest 
perfection  in  man,  especially  in  the  frontal  lobes.  Though  it 
would  not  be  suitable  to  put  forward  conceptions  going  into 
particulars  about  these  relations,  still  it  is  easy  to  think  before 
everything  of  the  process  of  abstraction,  which  transforms 
perceptions  to  general  ideas,  sensations  to  emotions,  impulses 
to  permanent  trends  of  volition.  These  abstract  creations  of 
the  higher  psychic  activity  are  what  the  essence  of  the 
psychic  personality  is  compacted  of  As  a  permanent  deposit 
of  the  experiences  of  life  they  dominate  the  thought,  feeling 
and  will  of  man  for  long  periods,  and  up  to  a  certain  degree 
make  it  independent  of  the  experiences  of  the  moment,  which 
through  it  are  reinforced,  moderated,  corrected,  or  in  certain 
circumstances  even  shown  to  be  false.  One  may  probably 
with  impunity  lay  stress  upon  the  fact,  that  in  dementia 
praecox  apparently  it  is  the  loss  of  those  permanent 
foundations  of  the  psychic  life,  as  they  are  created  by 
abstraction,  which  influences  the  clinical  picture  often  in  the 
highest  degree  in  incoherence  of  thought,  in  contradictory 
change  of  emotions,  in  impulsiveness  of  action. 


MORBID   ANATOMY  221 

The  small-celled  layers  extend  in  fairly  uniform  structure 
over  nearly  the  whole  surface  of  the  brain.  The  hypothesis, 
therefore,  is  easy  that  besides  the  task  of  abstraction,  perhaps 
in  connection  with  it,  they  have  also  the  task  of  mediating 
between  the  activities  of  the  deeper  layers  which  are  more 
confined  to  circumscribed  areas,  especially  sensory  perceptions 
and  volitional  impulses.  The  real  psychic  elaboration  of 
external  experience,  the  linking  of  it  on  to  past  experiences, 
the  critical  judgment  of  it  by  means  of  formerly  acquired 
standards,  the  connecting  of  it  to  new  psychic  structures,  to 
conclusions  and  creative  ideas,  could  even  so  be  ascribed  to  an 
organ  gathering  things  together  in  that  way,  as  the  prepara- 
tion for  action  by  weighing  values,  the  ripening  of  decisions 
on  the  ground  of  deliberation.  It  is  evident  that  the  activities 
named  here  must  before  everything  else  be  regarded  as 
foundations  of  the  inner  unity  and  consistency  of  the  psychic 
life.  The  fact  that  the  working  of  external  influences  is 
essentially  determined  by  the  permanent  character  of  the 
personality  concerned,  and  that  in  the  other  direction  action 
represents  the  outflow  of  the  whole  experience  of  life, 
necessarily  forces  us  to  the  assumption,  that  the  organ  of 
our  psychic  life  must  also  contain  mechanisms  which  mediate 
a  general  connection  of  all  the  psychic  workshops  among 
each  other.  Just  the  destruction  of  the  psychic  personality, 
of  this  inner  harmony  of  all  the  parts  of  the  psychic 
mechanism  in  perhaps  even  surprising  individual  activities 
is,  as  formerly  demonstrated,  the  real  fundamental  disorder 
in  dementia  praecox.  If  Alzheimer's  finding  is  proved  to  be 
invariably  present,  we  might  from  it  conclude  with  a  certain 
probability  that  in  the  small-celled  layers,  that  harmonious 
gathering  into  one  of  psychic  activities  takes  place,  the 
destruction  of  which  characterizes  dementia  praecox. 

This  hypothesis  gains  great  support  from  the  circum- 
stance, that  in  our  disease  the  lower  psychic  mechanisms 
as  a  rule  are  comparatively  little  encroached  on,  corresponding 
to  the  slighter  damage  done  to  the  deeper  cortical  layers. 
The  power  of  purely  sensory  perception  remains  often  fairly 
well  preserved,  as  also  the  memory  of  perceptions,  and 
acquired  knowledge  and  skill.  On  the  other  hand  judgment 
is  lost,  the  critical  faculty,  the  creative  gift,  especially  the 
capacity  to  make  a  higher  use  of  knowledge  and  ability. 
Pleasure  and  the  lack  of  it  are  often  perceived  by  the 
patients  with  the  greatest  intensity,  but  the  sense  of  beauty, 
the  joy  in  understanding,  sympathy,  tact,  reverence,  desert 
them,  as  also  the  intelligent,  continuous  emotional  relations 
to  the  events  of  life.    The  patients  may  also  exhibit  volitional 


222  DEMENTIA    PRECOX 

activity  of  the  greatest  strength  and  endurance,  but  they  are 
wholly  incapable  of  arranging  their  lives  according  to  rational 
principles  or  of  consistently  carrying  out  a  well-considered 
plan.  We  see,  therefore,  in  all  the  domains  of  psychic  life 
the  ancestral  activities  offering  a  greater  power  of  resistance 
to  the  morbid  process  than  the  psychic  faculties  belonging 
to  the  highest  degrees  of  development,  corresponding  to  the 
slighter  damage  done  to  the  deeper  cortical  layers  which 
are  more  like  those  of  the  lower  animals,  in  contrast  with 
those  which  only  attain  to  development  with  the  appearance 
of  the  most  complicated  psychic  activities. 

The  transparency  of  this  relation  is  somewhat  clouded 
by  the  fact,  that  memory  being  well  preserved  may  make 
possible  the  continuance  of  individual  capabilities  which  are 
much  exercised.  We  may  well  assume  that  the  site  of  both 
sensory  and  mechanical  memory  is  to  be  sought  for  princi- 
pally in  the  deeper  cortical  layers,  the  former  in  the  sensory 
centres,  the  latter  in  the  areas  which  mediate  the  harmony 
of  movements.  The  experience  which  has  been  formerly 
acquired  is  able  up  to  a  certain  point  to  cover  the  destruction 
of  the  higher  faculties,  just  so  far  as  independent  psychic 
activity  may  be  replaced  by  acquired  proficiency.  Precisely 
work  which  is  dependent  on  understanding  is  often  served 
by  associations  of  ideas  and  habits  of  thought  which  have 
been  firmly  laid  down  in  forms  of  speech,  while  in  the  domains 
of  the  emotional  life  and  of  action  an  adjustment  to  the 
special  conditions  of  the  given  moment  is  requisite  in  far 
higher  degree.  Perhaps  there  lies  in  this  an  essential  ground 
for  the  clinical  experience,  that  the  disorders  of  dementia 
praicox  usually  appear  here  earlier  and  in  more  severe  form 
than  in  intellectual  activities. 

But  further  by  the  destruction  of  the  harmonious  person- 
ality which  holds  together  and  dominates  the  whole  psychic 
life,  there  is  given  to  the  influence  of  ancestral  mechanisms 
a  free  play  which  they  could  never  otherwise  acquire.  To 
these  namely  I  reckon  the  activities  of  automatic  obedience 
and  negativism,  which  are  not  set  in  motion  by  deliberation 
or  moods,  but  appear  and  disappear  irregularly.  Stereotypy 
also,  as  a  general  expression  of  the  facilitating  action  of 
volitional  impulses,  might  come  in  here,  as  also  the  rhythmic 
movements  characteristic  of  profound  idiocy.  Lastly  in  the 
mannerisms  and  derailments  of  action  one  might  see  the 
consequence  of  defective  consciousness  of  purpose  and  defec- 
tive precision  of  volitional  impulses,  which  makes  them  more 
easily  accessible  to  all  kinds  of  side-influences.  Similarly 
neologisms  and   the  manifold   disorders  in  the  structure  of 


MORBID   ANATOMY  223 

speech  may  probably  be  connected  with  loosening  of  the 
connection  between  abstract  ideas,  speech  sounds  and  speech 
movements  and  with  defective  characterization  of  speech 
formulae ;  all  these  are  disorders  which  may  be  brought 
under  the  general  point  of  view  above  discussed  without 
special  difficulty.  In  the  roughest  outlines,  therefore,  clinical 
experience  and  anatomical  findings  in  dementia  prajcox  may 
with  certain  presuppositions  be  brought  into  agreement  to 
some  extent.  It  must  naturally  be  left  to  the  future  to 
decide  whether  and  how  far  such  considerations  stand  the 
test  of  increasing  knowledge. 


CHAPTER    IX. 
FREQUENCY  AND   CAUSES. 

Dementia  praicox  is  without  doubt  one  of  the  most 
frequent  of  all  forms  of  insanity.  Its  share  in  the  admissions 
to  a  mental  hospital  is  naturally  subject  to  very  considerable 
fluctuations,  not  only  according  to  the  delimitation  of  the 
morbid  picture,  but  also  specially  according  to  the  conditions 
of  admission.  With  us  approximately  lo  per  cent,  of  the 
admissions  might  belong  to  it,  while  the  proportion  in 
Heidelberg  amounted  to  nearly  15  per  cent.,  because  there, 
through  formalities  which  made  things  difficult,  a  large 
number  of  slight  cases  of  other  kinds  were  kept  out. 
Albrecht  states  the  frequency  for  Treptow  at  29  per  cent. ; 
to  the  real  mental  hospitals  only  those  patients  go,  who  are 
absolutely  in  need  of  institutional  treatment,  and  the  cases  of 
dementia  prnecox  are  in  the  first  ranks  of  these.  As  the 
patients  neither  quickly  die  off  like  the  paralytics,  nor 
become  in  considerable  number  again  fit  for  discharge 
like  the  manic-depressive  cases,  they  accumulate  more  and 
more  in  the  institutions  and  thus  impress  on  the  whole 
life  of  the  institution  its  peculiar  stamp.  In  the  private 
institutions  with  a  smaller  number  of  admissions  the  share  of 
our  patients  may  in  the  total  amount  rise  to  70  or  80  per  cent. 

The  Causes  of  dementia  praecox  are  at  the  present  time 
still  wrapped  in  impenetrable  darkness.  Indubitably  certain 
relations  to  age  exist.  The  very  great  majority  of  cases 
begin  in  the  second  or  third  decade ;  57  per  cent,  of  the 
cases  made  use  of  in  the  clinical  description  began  before 
the  twenty-fifth  year.  This  great  predisposition  oi youth  led 
Hecker  to  the  name  hebephrenia,  "  insanity  of  youth,"  for  the 
group  delimited  by  him  ;  Clouston  also,  who  spoke  of 
an  "  adolescent  insanity,"  had  evidently  before  everything 
dementia  praecox  in  view,  although  he  did  not  yet  separate 
it  from  the  manic-depressive  type  which  likevvi.se  often  begins 
about  this  time.  Hecker  was  even  inclined  to  regard  the 
issue  of  his  hebephrenia  just  as  an  arrest  of  the  whole 
psychic  life  on  the  developmental  stage  of  the  years  of 
puberty.     In  fact,  we  find  in  silly  dementia  at  least  many 


FREQUENCY   AND   CAUSES  225 

features  which  are  well  known  to  us  from  the  years  of 
healthy  development.  Among  these  there  is  the  tendency  to 
unsuitable  reading,  the  naive  occupation  of  the  mind  with 
the  "  highest  problems,"  the  crude  "  readiness  "  of  judgment, 
the  pleasure  in  catch  words  and  sounding  phrases,  also 
sudden  change  of  mood,  depression  and  unrestrained  merri- 
ment, occasional  irritability  and  impulsiveness  of  action. 
Further  the  desultoriness  of  the  train  of  thought,  the  half- 
swaggering,  boastful,  half-embarrassed,  shy  behaviour,  the 
foolish  laughing,  the  unsuitable  jokes,  the  affected  speech, 
the  sought-out  coarseness  and  the  violent  witticisms  are 
phenomena  which  in  healthy  individuals,  as  in  the  patients, 
indicate  that  slight  inward  excitement  which  usually  accom- 
panies the  changes  of  sexual  development.  However,  we 
shall  not  yet  be  able  to  conclude  from  these  similarities  that 
there  are  causal  relationships  between  dementia  praecox  and 
puberty,  as  a  limitation  of  the  disease  to  the  time  of  develop- 
ment does  certainly  not  take  place. 

The  diagram,  Fig.  42,  represents  the  distribution  of  1054 
cases  with  regard  to  age.  The  first  striking  thing  there  is, 
that  the  commencement  of  the  malady  for  a  certain  percent- 
age of  the  cases  is  placed  in  the  earliest  years  of  life.  It  has 
to  do  here  with  a  group  of  patients  in  whom  already  from 
childhood  upwards  a  considerable  degree  of  psychic  weakness 
existed,  although  the  more  striking  morbid  phenomena 
only  later,  perhaps  in  the  third  decade,  became  noticeable  and 
now  led  to  fairly  severe  dementia.  As  there  dementia 
praecox  was  in  a  certain  manner  grafted  upon  an  already 
existing  disease,  we  speak  in  such  cases  of  an  "  engrafted 
hebephrenia."  The  proportion  taken  here  of  3*5  per  cent,  is 
probably  much  too  small,  as  only  the  most  severe  instances 
of  that  kind  of  case  were  separated  out.  Slighter  divergencies 
of  the  most  varied  kind  occurred  moreover  very  frequently, 
a  circumstance  to  which  we  shall  later  return.  At  this  point 
it  must  already  be  emphasized  that  the  determination  of  the 
point  of  time  at  which  the  disease  began,  is  often  very 
uncertain  and  arbitrary  owing  to  the  development  being  so 
frequently  insidious.  If  it  were  wished  to  apply  a  very  strict 
standard  here,  the  whole  diagram  of  age  would  certainly  be 
dislocated  not  inconsiderably  towards  youth. 

The  decrease  in  the  percentage  between  the  tenth  and  the 
fifteenth  year  is  in  so  far  artificial,  that  this  number  is  not 
directly  comparable  with  the  number  of  engrafted  hebephrenias 
existing  from  youth  up.  From  that  time  on  we  see  the 
frequency  of  dementia  praecox  increasing  with  extraordinary 
rapidity,  more  than  two-thirds   of  the  cases  begin    between 

P 


226 


DKMF.XTIA    PR/ECOX 


the  fifteenth  and  the  thirtieth  year,  a  quarter  between  the 
twentieth  and  twenty-fifth  year.  However,  there  can  be  no 
talk  of  an  inviolable  connection  of  dementia  pr.xcox  with  the 
period  of  youth.  We  see  the  vertical  lines  of  the  diagram 
fall  off  fairly  quickly,  it  is  true,  but  yet  with  regularity,  and 


Fig.  42.   Percentage  distribution  of  1054  cases  of  dementia 
precox  according  to  age.     (J  =  years.) 

a  not  inconsiderable  number  of  cases  still  reach  development 
in  the  fourth,  fifth  and  even  in  the  sixth  decade. 

It  must  be  allowed  here  that  the  objection  is  suggested 
by  the  great  excess  of  cases  among  the  young,  that  the  ca.ses 
apparently  beginning  late  had  in  reality  begun  insidiously 
much  further  back,  though  the  more  striking  morbid  mani- 
festations only  became  noticeable  after  the  lapse  of  many 
years  and  even  decades.     In  general  this  objection  is  justified. 


FREQUENCY   AND   CAUSES  227 

Without  doubt,  especially  in  vagrants  and  criminals,  a  change 
of  personality  may  gradually  develop  in  youth,  the  morbidity 
of  which  is  only  recognized  much  later,  when  the  known 
phenomena  of  dementia  pnecox  become  associated  with  it, 
auditory  hallucinations,  delusions,  states  of  excitement  or 
stupor,  incoherence,  mannerisms.  However,  it  would  hardly 
do  in  some  respects  to  set  aside  the  share  of  the  more 
advanced  ages  in  dementia  prrecox  because  of  such  considera- 
tions. The  number  of  cases,  the  commencement  of  which 
would  have  to  be  displaced  more  or  less  far  back,  would  in 
any  case  up  to  the  fortieth  and  forty-fifth  year  be  so  large 
that  it  would  be  necessary  to  have  uncommonly  conclusive 
arguments  to  justify  such  a  proceeding.  Such  arguments, 
however,  are  actually  not  forthcoming.  So  long  as  the  view 
represented  by  Hecker  for  hebephrenia  held,  that  there 
existed  close  causal  relations  between  dementia  praecox 
and  puberty,  the  attempt  could  be  made  to  find  another 
explanation  for  the  cases  which  did  not  fit  this,  or  to  separate 
them.  Experience  has,  however,  meantime  taught  that  the 
greatest  frequency  of  the  cases  falls  at  an  age  in  which  sexual 
development  is  essentially  excluded.  If  already  by  that  a 
dependence,  in  the  narrower  sense  really  causal,  of  the  disease 
on  the  processes  of  puberty  becomes  improbable,  it  may 
further  be  pointed  out,  that  we  also  very  frequently  see  manic- 
depressive  insanity  begin  at  the  end  of  the  second,  or  in  the 
beginning  of  the  third  decade,  a  circumstance  which  only 
admits  of  the  interpretation  that  at  this  age  the  tendency  to 
psychic  disease  is  in  any  case  specially  great. 

The  view  here  represented  receives  further  support  from 
the  fact  that,  even  if  in  the  first  place  we  leave  engrafted 
hebephrenia  wholly  apart,  cases  occur  already  in  childhood, 
which  with  the  greatest  probability  we  may  classify  as 
dementia  praecox.  Long  ago  I  brought  forward  the  hypothesis 
that  certain,  not  exactly  frequent,  forms  of  idiocy  with 
developed  mannerisms  and  stereotypies  might  be  early  cases 
of  dementia  praecox.  Weygandt  -has  not  accepted  this 
interpretation,  as  he  asserts  that  the  phenomena  mentioned 
merely  signify  the  appearance  of  childish  forms  of  movement 
with  inhibition  of  the  higher  development  of  volition  by  some 
or  other  morbid  process.  With  this  view  already  formerly 
developed  by  myself  I  can  agree  so  far  as  it  concerns  the 
peculiar  rhythmic  movements  of  idiocy.  I  might  take  the 
view  indicated  of  the  sucking  reflex  also,  which  appears  in 
very  severe  dementias  (paralysis,  Alzheimer's  disease),  and 
further  of  certain  springing,  rubbing  "  movements  of  suck- 
lings "  which  are  observed  in  young  paralytics.     On  the  other 


228 


DEMENTIA    PRECOX 


hand,  the  swaggering  manners  of  some  idiots,  and  likewise 
many  stereot)'pies  of  attitude  and  movement  which  are 
connected  with  these,  and  lastly  negativistic  features  which 
accompany  them,  e.g.,  permanent  repellent  inaccessibility  to 
all  attempts  at  approach,  appear  to  me  to  have  no  relation  at 

all  to  general  childish  peculi- 
arities but  much  rather  to  belong 
to  the  well-known  morbid  picture 
of  dementia  prjtcox.  One  of  my 
patients  had  the  habit  of  re- 
peatedly hitting  his  plate  with 
his  fork,  waving  his  hat,  dipping 
his  bread  again  and  again  into 
his  cup,  scraping  all  round  his 
roll,  doing  everything  twenty  or 
thirty  times.  A  patient  aged 
twenty-three  years  is  represented 
in  Fig.  43,  who  was  from  child- 
hood idiotic,  dull,  inaccessible, 
but  otherwise  clean,  who  carried 
out  incessant,  senseless,  spread- 
ing movements  with  his  hands. 
Complete  certainty  about  the 
significance  of  such  observations 
will,  it  is  true,  only  be  obtained 
by  anatomical  investigation.  I 
may,  however,  point  out  that  in 
one  of  my  cases,  the  beginning 
of  which  reached  back  into  the 
fourth  year,  and  in  which  an 
extremely  characteristic  negativ- 
istic dementia  had  come  into 
existence,  the  patient's  mother 
also  exhibited  the  picture  of 
dementia  prscox. 

Recently  Sante  de  Sanctis^ 
has  described  under  the  name 
of  "  demenza  precocissima "  a 
series  of  morbid  conditions 
observed  in  young  children,  which  are  accompanied  by 
"  catatonic  "  phenomena  ;  some  of  these  cases  are  cured,  but 
others  issue  in  psychic  weakness  of  greater  or  less  degree. 
As   he    himself  emphasizes,   it   can    scarcely  be  decided  at 

'  Sante  de  Sanctis,  Rivista  ital.  di  neuropat.,  psicliiatria  ed  elettroterap  ii.  3  ; 
Folia  neurolofjica  ii.  9;  iii.  395;  Weygandt,  Zeitschr.  f.  d.  Erf.  d.  jugendl. 
Schwachsinns  i.  311. 


1-ig.  43- 


Idiot  with  manneristic 
movements. 


FREQUENCY   AND   CAUSES  229 

present  how  far  the  cases  described  belong  to  dementia 
prascox  or  to  other  forms  of  disease,  among  which  indeed 
specially  hysteria  and  infections,  also  syphilitic  cases  might 
come  into  consideration.  However,  the  clinical  agreement  of 
some  morbid  states,  which  develop  in  the  first  or  at  the 
beginning  of  the  second  decade,  with  the  dementia  praicox  of 
adults,  in  phenomena,  course  and  issue  is  so  apparent,  that 
there  can  be  no  reasonable  doubt  about  the  relationship.  I 
have  myself  observed  several  such  cases  and  Racke  and  Vogt 
also  have  communicated  some.  Lastly,  Heller  has  described 
as  "dementia  infantilis"  cases  which  begin  in  the  third  or 
fourth  year,  sometimes  run  their  course  violently,  sometimes 
insidiously,  and  issue  in  profound  dementia  with  stereotypies 
and  mannerisms.  Here  also  we  shall  be  obliged  to  think  of 
the  probability  that  at  least  many  of  these  cases  belong  to 
dementia  praecox. 

If  in  the  interpretation  of  the  morbid  pictures  appearing 
in  earliest  childhood  we  find  ourselves  often  on  ground  at 
present  still  rather  insecure,  the  same  applies  to  the  cases  in 
the  years  of  involution,  which  run  their  course  according  to 
the  picture  of  dementia  praecox.  Here  without  doubt  there 
are  on  the  one  hand  cases,  which  according  to  our  present 
knowledge  cannot  by  any  means  be  separated  from  the 
forms  beginning  earlier,  which  we,  therefore,  may  term 
genuine  "  late  catatonias."  ^  Petren  observed  twenty-four 
cases  of  catatonia  after  the  fortieth  year,  among  them  six 
between  fifty  and  fifty-five,  one  of  fifty-eight  and  one 
of  fifty-nine  years  of  age.  Schroder  also  quotes  a  case 
which  began  at  fifty-nine  years.  Zweig  has  brought  together 
thirteen  cases  between  the  thirtieth  and  fortieth  year  and 
five  cases  after  the  fortieth,  and  arrives  at  the  result,  that 
they  correspond  in  general  to  those  of  a  younger  age  ;  only 
the  prognosis  appeared  to  him  to  be  comparatively  favour- 
able, a  conclusion  for  which  the  number  of  his  observations 
is  by  no  means  sufficient,  and  which  in  Zablocka's  com- 
munications finds  no  confirmation.  It  is  very  noteworthy 
that  Schroder  found  four  cases  among  sixteen  late  catatonias, 
in  which  twelve  to  twenty-five  years  previously  very  slight 
attacks,  mostly  states  of  depression,  had  preceded.  The 
hypothesis  formerly  touched  on,  that  it  may  here  sometimes 
be  only  a  case  of  the  flaring  up  of  a  morbid  process  reaching 
far  back  in  an  inconspicuous  form,  finds  in  this  experience  a 
certain  confirmation.  Bertschinger  also  has  pointed  out  this' 
possibility.     Petren  reports  a  case  which  at  nineteen  years  of 

^  Sommer,  Zeitschr.  f.  d.  ges.  Neurol,  u.  Psychiatric,  i.  533. 


230  DEMENTIA    PR^ECOX 

age  passed  through  an  attack  of  hebephrenia  and  recovered 
with  defect,  and  then  at  the  age  of  forty-four  fell  ill  again. 

It  must  meantime  be  acknowledged  that  specially  in  the 
years  of  involution  we  not  at  all  infrequently  meet  with 
cases,  the  clinical  judgment  of  which  even  now  meets  with 
the  greatest  difficulties.  Here  it  has  to  do  at  one  time  with 
cases  which  run  their  course  with  intense  and  anxious  states 
of  excitement  and  depressive  delusions,  also  with  catatonic 
symptoms,  automatic  obedience,  inaccessibility,  resistance, 
stereotyped  attitudes  and  movements,  and  issue  with  com- 
parative rapidity,  sometimes  even  after  a  temporary  improve- 
ment, in  profound  psychic  decline;  at  another  time  it 
is  a  case  of  paranoid  forms.  I  consider  it  probable  that  here 
we  have  partly  to  do  with  morbid  processes  which  do  not 
belong  to  dementia  praecox,  although  a  satisfactory  delimita- 
tion and  especially  a  decision  in  individual  cases  at  present 
is  still  scarcely  possible.  So  far  as  the  purely  clinical  view 
allows  us,  I  have  made  the  attempt  in  the  discussion  of  the 
presenile  and  paranoid  cases  to  fix  some  points  of  view  for 
new  morbid  pictOres,  An  essential  hindrance  to  the  success 
of  such  attempts  lies,  however,  in  the  circumstance,  that  the 
clinical  forms  of  dementia  praecox  not  only  exhibit  in  them- 
selves an  extraordinary  variety,  but  that  they  also,  as 
formerly  mentioned  in  detail,  are  distinctly  influenced  by 
age.  The  decision  as  to  which  morbid  disorders  of  the  age 
of  involution  are  to  be  reckoned  with  dementia  praecox  and 
which  are  to  be  regarded  as  psychoses  of  another  kind,  will 
therefore  always  depend  on  the  question,  how  far  the 
differences  in  the  form  of  the  clinical  phenomena  are  con- 
ditioned by  the  character  of  the  morbid  process  and  how  far 
by  the  changes  of  advancing  age  in  the  personality. 

The  difficulties  here  touched  on  have  caused  Stransky, 
under  the  term  "dementia  tardiva,"^  to  delimit  certain 
paranoid  cases  of  the  years  of  involution  with  indications 
of  catatonic  features  particularly  in  women  as  a  special 
clinical  form.  Hallucinations,  change  of  mood  without  very 
severe  dulling  of  emotions,  passing  states  of  lively  excite- 
ment, delusions  without  systematic  elaboration,  indications 
of  catatonic  features  characterize  the  morbid  picture.  It 
must  remain  for  the  future  to  decide  whether  dementia 
tardiva  represents  a  clinical  entity,  or  whether,  as  I  for 
the  present  consider  more  probable,  it  must  be  broken  up  into 
various  groups  according  to  the  points  of  view  indicated. 

Sex. — The  male  .sex  appears  in  general  to  suffer  .some- 
what   more   frequently    from    dementia    pr.-ecox    than    the 

^  Stransky,  Monatsschr.  f.  Psychiatric  u.  Neurol,  xviii.  Erg.-Heft. 


FREQUENCY    AND   CAUSES  231 

female ;  among  the  1054  cases  utilized  for  our  age-diagram 
there  were  57*4  per  cent.  men.  In  the  individual  clinical 
forms  meantime,  as  we  have  formerly  seen,  the  share  of  the 
sexes  exhibits  not  inconsiderable  differences.  The  same 
holds  good  for  the  different  ages,  as  the  following  table  of 
the  number  of  men  in  the  different  periods  of  life  shows: — 

Age  .  . — 10  — 15 — 20  — 25  — 30 — 35  —40  — 45 — 50 — 55—60 
Men  per  cent.     70*3   500  658   63-6   579   50-4  60-4   343   540  33-4  00 

Engrafted  hebephrenia  appears  therefore  to  be  more 
frequent  in  the  male  sex  ;  but  in  the  next  period  both  sexes 
are  attacked  in  the  same  degree.  After  the  fifteenth  year 
the  male  sex  predominates  greatly,  then  less,  till  between 
the  thirtieth  and  the  thirty-fifth  year,  equality,  though  only 
temporarily,  is  again  reached.  After  the  fortieth  year  women 
predominate  especially  at  the  most  advanced  ages,  but  the 
numbers  from  which  the  percentages  are  taken  after  the 
forty-fifth  year  are  too  few  to  be  of  use.  It  may  be 
mentioned,  however,  that  Schroder  found  among  his  "late 
catatonias "  three  men  and  thirteen  women  ;  Sommer  also 
emphasizes  the  predominance  of  the  female  sex.  Considera- 
tion of  the  figures  might  in  any  case  show  at  least,  that  the 
tendency  of  the  female  sex  to  attacks  of  dementia  praecox, 
which  on  the  average  is  somewhat  less,  experiences  a  certain 
increase  in  three  different  periods  of  life,  before  the  fifteenth, 
between  the  twenty-fifth  and  thirty-fifth,  and  after  the  fortieth 
year.  There  will  certainly  be  a  temptation  here  to  think  .of 
sexual  development  which  is  earlier  in  the  woman,  of  the 
time  of  the  work  of  reproduction  and  of  the  years  of 
involution. 

General  Conditions  of  Life. — Since  attention  has  been 
drawn  to  the  morbid  picture  of  dementia  praecox,  it  has 
been  shown  that  in  all  civilized  nations  it  comes  under 
observation  in  approximately  the  same  forms  and  everywhere 
accounts  for  the  greatest  number  of  the  permanent  inhabi- 
tants of  institutions.  As  the  progressive  increase  of  these 
patients  seemed  to  prove  most  obviously  the  increase  of 
insanity,  it  was  easy  to  think  of  dementia  praecox  as  a 
product  of  the  injuries  to  which  the  progress  of  civilization 
and  its  unpleasant  accompaniments  exposes  our  mental 
health.  Mental  over-exertion,  especially  in  the  years  of 
development,  on  the  other  hand  degeneration,  were  frequently 
regarded  as  the  causes  of  the  malady.  It  appeared  to  me, 
therefore,  of  especial  importance  to  ascertain  whether  the 
disease  appeared  also  in  nations,  which  live  in  quite  different, 
and  especially  more  simple  and  more  natural  conditions,     A 


232  DEMENTIA    PRvECOX 

yisit  to  the  institution  in  Singapore  at  once  showed  me  that 
in  the  most  different  constituent  parts  of  the  mingling  of 
nations  there,  among  Chinese,  Tamils,  Malays,  there  were 
clinical  pictures  to  record  which  wholly  resemble  the  forms 
of  dementia  pra;cox  known  to  us.  The  later  more  exact 
investigation  in  the  institution  Buitenzorg  brought  out  the 
result  that  the  greatest  number  of  the  inmates  there,  con- 
sisting of  Malays,  Javanese,  Sundanese  and  Chinese  all 
thrown  together,  almost  80  per  cent.,  presented  morbid 
pictures  about  which  it  could  scarcely  be  doubted  that  they 
belonged  to  dementia  pra;cox.  There  were,  it  must  be 
admitted,  in  the  character  of  the  individual  features  very 
remarkable  differences  from  the  forms  familiar  to  us  ;  the 
disease  began  for  the  most  part  with  states  of  confused 
excitement,  which  then  with  comparative  rapidity  led  to 
drivelling  dementia  with  incoherence,  exalted  mood,  loquacity 
and  mannerisms.  Since  then  the  frequent  occurrence  of 
dementia  prcxcox  in  the  most  different  regions  of  the  world 
has  been  confirmed ;  Koichi  Miyake  reports  that  it  occurs  in 
Japan  just  the  same  as  with  us,  only  with  less  tendency  to 
states  of  depression. 

If  we  must  therefore  seek  the  real  cause  of  dementia 
praecox  in  conditions  which  are  spread  over  the  whole  world, 
which  thus  do  not  lie  either  in  race  or  in  climate,  in  food  or 
in  any  other  general  circumstances  of  life,  we  are  still  not 
able  to  say  anything  as  to  whether  the  factors  mentioned 
have  not  perhaps  a  furthering  influence  on  the  development 
of  the  disease,  as  reliable  statistical  facts  on  this  point  have 
not  been  collected.  We  know  nothing  about  the  relative 
frequency  of  dementia  pra.'cox  in  individual  nations,  in 
different  conditions  of  life,  in  town  and  country,  at  different 
times.  Only  so  much  may  be  said,  that  the  disease  is  prob- 
ably extremely  old,  as  indeed  the  descriptions  of  the  old 
physicians  often  unmistakably  point  to  the  clinical  pictures 
familiar  to  us. 

Hereditary  Predisposition. — Of  the  causal  conditions  of 
dementia  praecox  accessible  to  our  investigation  at  present 
hereditary  predisposition  ^  must  next  be  named.  The  figures 
stated  for  this  point  vary  considerably  among  themselves, 
evidently  according  to  the  extent  which  is  attached  to  the 
idea  of  heredity,  as  also  according  to  the  accuracy  of  the 
information  which  can  be  got  about  the  families  of  the 
patients.  Schott  finds  hereditary  taint  in  52  per  cent., 
Lukacs  in  53*8  per  cent,  Meyer  in  54  per  cent,  Karpas  in 

'  Levi-Bianchini,    Rivista   sperimentale  di  freniatria  xxix.    558;    Berze,    Die 
hereditaren  Beziehungen  der  Dementia  praecox,  1910. 


FREQUENCY   AND   CAUSES  233 

64  per  cent.,  S^rieux  in  70  per  cent.,  Wolfsohn  and  also 
Zablocka  in  90  per  cent,  of  the  cases.  I  had  myself  found 
forrtierly  in  Heidelberg  general  hereditary  predisposition  to 
mental  disorders  in  about  70  per  cent,  of  the  cases  in  which 
about  this  point  reliable  statements  were  to  hand.  As  by 
this  restriction  it  naturally  resulted  that  a  certain  selection 
was  made,  the  proportion  might  be  somewhat  too  high. 
Among  the  1054  cases  made  use  of  above  there  were  538  per 
cent,  in  which  the  family  history  gave  support  to  the  assump- 
tion of  hereditary  taint.  This  figure  is  certainly  too  small, 
because  in  numerous  cases  the  information  about  the  ancestors 
of  the  patients  was  very  incomplete.  Perhaps  it  is  possible 
to  get  somewhat  more  reliable  figures  if  one  limits  oneself  to 
direct  heredity,  that  is  to  the  occurrence  of  mental  disorders, 
suicide  or  severe  brain  diseases  in  the  parents,  as  about  this 
question  it  is  easiest  to  get  trustworthy  statements.  Within 
this  limitation  there  was  found  a  direct  taint  in  337  per  cent, 
of  the  cases,  a  number  which  on  the  grounds  named  must 
still  be  regarded  as  too  low ;  that  appears  also  from  the  fact 
that  the  admissions  in  Heidelberg  with  their  more  complete 
previous  histories  yielded  a  higher  value  than  the  patients 
admitted  often  without  any  information  in  the  city  of  Munich. 
But  to  that  must  be  added  that  in  7*9  per  cent,  of  the 
cases  alcoholism  in  one  of  the  parents  was  present ;  this 
figure  contrariwise  is  for  Munich  somewhat  higher  than  for 
Heidelberg.  In  2  per  cent,  of  the  cases  lastly  besides  the 
direct  taint  of  mental  disorders  alcoholism  had  also  to  be 
recorded  in  one  of  the  parents. 

If  these  figures  are  compared  with  those  got  by  Diem, 
it  results  that  the  taint  from  the  morbid  condition  of  the 
parents  here  taken  into  consideration  is  perhaps  10  per  cent, 
higher  than  in  mentally  healthy  individuals,  and  therefore 
causal  relations  must  be  regarded  as  probable.  To  the  same 
view  must  the  experience  lead,  that  dementia  praecox  not 
at  all  infrequently  is  familial^  ftiost  often  appearing  in 
brothers  and  sisters,  more  rarely  in  parents  and  children, 
as  the  disease,  because  of  its  early  development  and  its 
serious  phenomena,  encroaches  on  the  reproductive  capability 
to  a  high  degree.  I  know  a  very  great  number  of  cases 
in  which  several  brothers  and  sisters  were  attacked  with 
dementia  praecox,  sometimes  in  startlingly  similar  ways  ;  once 
three  members  of  the  same  family  were  admitted  very  shortly 
one  after  the  other.  Schwarzwald  ^  describes  three  series 
of  cases,  in  which  each  time  three  sisters,  and  one  in  which 
five  sisters  were  attacked  with  the  symptoms  of  dementia 
^  Schwarzwald,  De  la  demence  precoce  familiale.  Diss.  1907. 


234  DEMENTIA    PRECOX 

pr.-ccox.  Frankhauser  reports  twenty-eight  pairs  of  brothers 
and  sisters  who  succumbed  to  the  same  malady.  Not  in- 
frequently one  learns  further  that  among  the  brothers  and 
sisters  of  the  patients  there  are  found  striking  personalities, 
criminals,  queer  individuals,  prostitutes,  suicides,  vagrants, 
wrecked  and  ruined  human  beings,  all  being  forms  in  which 
more  or  less  well -developed  dementia  pra^cox  may  appear. 

If  such  cases  serve  as  evidence  of  a  similar  morbid  pre- 
disposition, on  the  other  hand,  however,  it  also  often  occurs 
that  among  the  members  of  some  families  disorders  of  quite 
another  kind  appear,  epilepsy,  hysteria,  manic-depressive 
insanity.  The  comprehensive  investigations,  which  Riidin 
has  carried  out  about  the  families  of  our  patients,  have  in 
the  frequency  of  the  familial  occurrence  of  dementia  praecox 
likewise  made  clear  the  important  part  played  by  hereditary 
predisposition.  Riidin  on  the  ground  of  his  researches  comes 
to  the  conclusion  that  dementia  prnecox  is  probably  trans- 
mitted according  to  Mendel's  law  and  indeed  as  a  recessive 
characteristfc.  He  has  as  evidence  the  great  predominance 
of  collateral  and  discontinuous  inheritance  compared  with 
direct  transmission,  its  increase  in  in-breeding  and  the  special 
numerical  ratio  of  those  attacked  in  individual  families  to 
those  who  remain  healthy.  He  finds  that  in  the  families 
attacked  there  comes  under  observation  with  relative  fre- 
quency besides  dementia  prrecox  a  series  of  other  anomalies, 
specially  manic-depressive  insanity  and  eccentric  personalities. 
While  the  latter  are  probably  for  the  most  part  to  be  regarded 
as  "  latent  schizophrenias  "  and  therefore  essentially  the  same 
as  the  principal  "malady,  the  relations  to  manic-depressive 
insanity  are  still  not  clear.  Riidin  found  that  manic-depres- 
sive parents  not  at  all  infrequently  have  children  with 
dementia  praecox,  while  the  reverse  case  belongs  to  the  rare 
exceptions  unless  there  also  exists  inherited  predisposition 
to  manic-depressive  insanity  from  the  other  side. 

Injury  to  the  Germ. — Besides  heredity,  however,  still 
other  influences  may  apparently  determine  the  appearance 
of  dementia  praecox.  That  is  proved  according  to  Riidin's 
experience  first  by  the  fact  that  first-born  and  late-born,  also 
last-born,  individuals  are  attacked  by  the  malady  with 
comparative  frequency.  Further  it  was  shown  that  not 
infrequently  immediately  before  or  after  the  birth  of  the 
individual  attacked  there  have  occurred  miscarriages,  dead- 
born  children,  premature  births ;  or  children  with  small 
vitality  or  with  bodily  or  mental  defects  may  have  been  born. 
The  assumption  is  suggested  by  such  observations  that 
influences  injurious  to  the  germ   might  play  a  certain  part 


FREQUENCY   AND   CAUSES  235 

in  the  origin  of  dementia  praecox.  Further  evidence  for  that 
is  given  by  the  observation,  confirmed  by  Riidin.that  alcoholism 
is  reported  in  the  parents  with  striking  frequency  ;  he  found 
it  at  least  sixty  times  in  300  accurately  investigated  cases. 
Wolfsohn  saw  chronic  alcoholism  in  one  of  the  parents  in 
a  fourth  of  the  cases,  while  I  could  demonstrate  it  in  my 
patients  often  with  incompletely  known  previous  history 
in  any  case  in  10  per  cent.  One  may  accordingly  assume 
that  parental  alcoholism  probably  exercises  a  certain  influence 
on  the  development  of  dementia  prnecox  in  the  children, 
a  connection  which  might  be  caused  by  injury  to  the  germ. 

In  the  same  sense  we  may  probably  interpret  the  state- 
ments made  by  Hirschl  and  Pilcz  about  the  occurrence  of 
syphilis  in  the  parents  of  our  patients.  Pilcz  reports  that  in 
416  cases  of  dementia  praecox  he  had  found  tabes  in  5  per 
cent,  of  the  parents,  in  manic-depressive  insanity  on-  the 
other  hand  only  in  0'6  per  cent.  In  the  parents  of  forty-four 
hebephrenic  patients  paralysis  was  found  twenty-three  times, 
in  those  of  twenty-seven  catatonics  five  times  ;  also  in  the 
brothers  and  sisters  of  our  patients  paralysis  was  observed 
with  striking  frequency  and  in  those  of  the  paralytic  often 
dementia  praecox.  In  the  parents  of  my  patients  I  got 
information  about  syphilis  only  in  4  to  5  per  cent. ;  further  it 
has  not  hitherto  struck  me  that  the  children  of  paralytics  are 
attacked  specially  often  by  dementia  praecox;  among  124 
such  children  of  whom  certainly  only  sixty-seven  had  passed 
their  tenth  year,  and  twenty-nine  their  twentieth  year,  two 
suffered  from  dementia  praecox.  On  the  other  hand  Klutscheff 
reports  that  in  sixty  cases  of  dementia  praecox  he  has  found 
in  4r6  per  cent,  signs  of  hereditary  syphilis.  As,  however, 
otherwise  there  is  no  evidence  of  any  kind  for  the  assumption 
,  that  dementia  praecox  may  be  directly  caused  by  hereditary 
syphilis,  confirmation  of  such  statements  might  probably 
only  point  to  a  general  injurious  action  of  parental  syphilis 
on  the  germ.  In  each  case  investigation  would  be  necessary, 
and  with  the  help  of  serological  procedure  comparatively 
easy  to  accomplish,  how  far  the  traces  of  syphilis  can  really 
be  demonstrated  in  the  parents  of  our  patients;  the  "stigmata" 
are,  as  is  well  known,  extraordinarily  deceptive. 

Personal  Idiosyncrasy. — For  the  view  that  in  the  origin 
of  dementia  praecox  degfneration  plays  a  part,  the  circum- 
stance is  usually  brought  forward  that  in  the  patients  from 
the  beginning,  physical  and  psychic  signs  of  degeneration  are 
frequently  found.  Saiz^  states  the  frequency  of  such  physical 
abnormalities,  which  are  usually  regarded  as  the  expression 

^  Saiz,  Rivista  di  freriiatria  sperimentale  xxxviii.  364. 


236  DEMENTIA    PR/ECOX 

of  degeneration,  as  74  per  cent.  Considering  the  great 
elasticity  of  the  limits,  which  in  ascertaining  such  facts  must 
be  allowed  for,  it  is  scarcely  possible  to  set  a  value  on  the 
figures.  But  it  corresponds  well  enough  to  the  general 
experience  that  in  patients  with  dementia  pra^cox  all  sorts 
of  physical  abnormalities  exist  with  striking  frequency, 
especially  weakliness,  small  stature,  youthful  appearance, 
malformation  of  the  cranium  and  of  the  ears,  high  and  narrow 
palate,  persistence  of  the  intermaxillary  bone,  abnormal 
growth  of  hair,  strabismus,  deformities  of  the  fingers  or 
toes,  polymastia,  defective  development  and  irregularity  of 
the  teeth  and  the  like.  Here  is  the  place  to  add  the  not 
infrequent  occurrence  of  convulsions  in  childhood,  of 
obstinate  nocturnal  enuresis,  of  frequent  headaches,  sensitive- 
ness to  alcohol,  tendency  to  delirium  in  slight  fever. 

But  much  more  important  than  the  physical  signs  of 
degeneration,  which  in  similar  guise  appear  in  many  other 
forms  of  insanity,  appears  to  me  the  fact  that  in  a  consider- 
able number  of  cases  definite  psychic  peculiarities  have  come 
under  observation  in  our  patients  from  childhood  up. 
Schultze  states  that  50  to '70  per  cent,  of  the  patients  were 
from  the  beginning  psychopathic,  and  exhibited  a  shy,  quiet, 
or  specially  in  the  female  sex,  an  irritable,  capricious 
character.  Karpas  found  among  his  patients  that  68  per 
cent,  were  psychopaths  ;  Schott  reports  that  28  per  cent, 
of  the  patients  were  quiet  and  reserved. 

I  also  have  examined  minutely  the  previous  history  of 
my  patients  for  the  occurrence  of  striking  psychic  predisposi- 
tion and  can  in  general  confirm  the  statements  of  the 
investigators  quoted,  though  I  would  abstain  from  giving 
definite  figures  because  of  the  incompleteness  of  the 
information  which  is  forthcoming  at  present.  It  was 
mentioned  with  very  special  frequency,  particularly  in  the 
male  sex,  that  children  were  mostly  concerned  who  always 
exhibited  a  quiet,  shy,  retiring  disposition,  made  no  friend- 
ships, lived  only  for  themselves.  Of  secondary  importance, 
and  more  in  girls,  there  is  reported  irritability,  sensitiveness, 
excitability,  nervousness,  and  along  with  these  self-will  and  a 
tendency  to  bigotry.  Then  a  smaller  group  of  children, 
mostly  boys,  is  noticeable,  who  from  childhood  up  were  lazy 
and  restless,  disliked  work,  were  inclined  to  nasty  tricks,  did 
not  persevere  anywhere,  and  then  became  vagrants  or 
criminals.  Somewhat  in  contrast  to  that  are  those  patients, 
likewise  belonging  rather  more  to  the  male  sex,  who  were  con- 
spicuous by  docility,  good  nature,  anxious  conscientiousness 
and  diligence,  and  as  patterns  of  goodness  held  themselves 


FREQUENCY   AND   CAUSES  237 

aloof  from  all  childish  naughtiness.  Intellectual  endowment 
I  found  among  my  patients  in  Heidelberg,  who  were  in  more 
favourable  circumstances  for  such  investigations,  in  17  per 
cent,  of  the  cases  stated  as  excellent,  in  about  one-third  of 
the  cases  as  moderate,  in  7  per  cent,  as  poor.  Evensen  puts 
down  67  per  cent,  of  his  patients  as  being  above  the  average, 
22  per  cent,  as  poorly  endowed  ;  Plaskuda  puts  down  15  per 
cent,  as  from  childhood  up  limited.  Schott  states  that  28  per 
cent,  of  his  patients  learned  with  difficulty,  40  per  cent,  on 
the  other  hand  were  good  to  very  good  scholars,  and  Levi- 
Bianchini  attributes  to  6  per  cent,  of  his  patients  great,  to 
60  per  cent,  medium,  and  to  24-4  per  cent,  slight  endowment. 

In  view  of  these  experiences  the  question  is  raised  in 
what  relation  the  psychopathic  abnormalities,  which  with 
striking  frequency  precede  the  development  of  dementia 
praecox,  stand  to  the  later  disease,  and  especially  whether 
they  are  only  the  expression  of  constitutional  injuries  which 
lower  the  power  of  resistance  to  the  cause  of  dementia  praecox, 
or  whether  it  is  a  case  of  the  first  indications  of  the  disease 
itself  reaching  back  into  childhood.  For  the  answer  to  this 
question  the  circumstance  seems  to  me  to  be  of  authoritative 
significance,  that  at  least  a  part  of  the  psychic  peculiarities 
quoted  exhibits  the  greatest  resemblance  to  those  disorders 
which  we  can  establish  in  the  incomplete  remissions  as 
well  as  in  the  cures  with  defect  of  our  patients.  In  numerous 
cases  we  see  here  as  a  residuum  of  the  disease  in  persons 
formerly  not  at  all  remarkable,  the  quiet,  shy,  retiring ; 
the  indocile,  stubborn  ;  the  irritable,  sensitive  ;  or  the  harm- 
less, good-natured  conduct  develop,  as  it  is  described  in 
changing  characters  in  the  previous  history  of  so  many 
patients.  Further,  it  must  be  pointed  out  that  we  not  at 
all  infrequently  see  a  change  in  the  personality,  in  the  sense 
here  indicated,  take  place  first  in  the  later  years  of  childhood, 
but  many  years  before  the  real  onset  of  dementia  precox. 
This  experience  may  probably  only  be  interpreted  as 
a  sign  that  the  morbid  process,  which  occurs  here  and 
first  begins  insidiously,  is  able  to  cause  the  same  peculiarities 
which  we  see  so  frequently  precede  its  appearance  from 
childhood  onwards. 

Here  perhaps  the  objection  may  be  made  that  the  peculi- 
arities which  meet  us  in  the  previous  history  of  our  patients 
could  also  be  found  in  similar  guise  in  any  other  group  of 
people  taken  at  random,  and  that  they  on  the  other  hand 
are  too  varied  to  be  the  expression  of  one  and  the  same 
morbid  process.  It  must  at  once  be  admitted  that  the  first 
objection    is  justified  ;    it  would  be  quite  necessary  for  the 


238  DEMENTIA    PRECOX 

right  appreciation  of  the  circumstances  to  carry  out  similar 
investitjjations  in  other  forms  of  disease  also,  but  especially 
also  in  healthy  individuals.  We  shall  later  have  to  discuss 
the  results,  which  have  been  got  up  to  now,  of  such  investiga- 
tions in  epilepsy  and  in  manic-depressive  insanity;  they 
show  that  the  previous  history  of  the  patients  here  does  yield 
essentially  abnormal  features.  It  is  true  that  there  are  also 
certain  points  of  agreement ;  but  we  may  not  leave  out  of 
account  that  our  characterization  of  personal  qualities  at 
present  is  still  very  rough,  that,  therefore,  under  the  same 
term,  which  is  used  by  the  relatives  for  the  description  of 
the  former  conduct  of  our  patients,  perhaps  a  series  of  wholly 
different  characteristics  is  comprehended.  If  this  source  of 
error  is  appreciated,  the  impression  is,  as  it  appears  to  me, 
so  overpowering,  which  is  got  from  the  statements,  always 
the  same,  of  the  relatives  about  the  former  personality  of 
our  patients,  that  there  cannot  well  be  any  doubt  about  the 
striking  frequency  of  very  definite  predisposition  in  the 
previous  history  of  dementia  pra^cox.  But  the  differences, 
the  very  contrast,  of  these  peculiarities  finds  its  exact  counter- 
part in  the  differences  of  the  clinical  pictures,  of  the  terminal 
states,  and  of  the  variations  observed  in  the  remissions.  It 
is  indeed  easy  enough  to  bring  the  reserved  or  stubborn 
conduct  of  the  children,  who  are  attacked  later,  into  nearer 
relation  with  the  negativism,  their  capriciousness  with  the 
mannerisms,  their  irritability  with  the  impulsiveness,  their 
good  conduct  with  the  automatic  obedience  of  dementia 
praecox. 

On  the  grounds  alleged  the  conclusion  seems  to  me  justi- 
fied that  the  psychic  abnormalities  which  precede  the  real 
onset  of  dementia  praicox  already  represent  in  part  at  least 
the  action  of  the  cause  of  the  disease,  even  if  they  can  be 
traced  back  into  the  first  years  of  the  patient's  life.  The 
commencement  of  the  malady  would  be,  if  this  view  should 
be  confirmed,  moved  back  into  childhood  for  a  considerable 
number  of  the  patients  ;  we  should  have  to  assume  a  longer 
or  shorter  preparatory  stage,  in  which  without  noticeable 
progress,  but  already  in  indications  the  disease  develops 
certain  results  such  as  we  find  again  most  strongly  marked 
at  the  height  of  its  development  and  in  the  terminal  stages. 
This  interpretation  finds  essential  support,  as  appears  to  me, 
in  the  dementia  prajcox  of  children  and  in  engrafted  hebe- 
phrenia. It  has  indeed  here  also  been  thought  that  it  was 
a  case  of  chance  coincidence  with  other  kinds  of  brain  disease 
which  only  favoured  the  development  of  dementia  pra_'Cox. 
But  engrafted  hebephrenia  is  on  the  one  hand  too  frequent 


FREQUENCY   AND   CAUSES  239 

for  the  explanation  to  have  much  probability  in  itself,  and 
on  the  other  hand  the  weak-mindedness,  which  is  its  founda- 
tion, bears  also  most  unmistakably  the  features  of  a  hebe- 
phrenic terminal  state,  and  the  fresh  attack  very  often  assumes 
the  features  of  a  simple  exacerbation  of  the  already  existing 
disorders.  As  in  addition  the  appearance  of  dementia 
precox  in  early  childhood  is  certain,  there  is  no  satisfac- 
tory reason  according  to  my  view  to  assume  in  engrafted 
hebephrenia  an  association  of  morbid  processes  of  a  totally 
different  kind. 

The  frequency  of  defective  or  poor  endowment  will  from 
this  standpoint,  so  far  as  it  is  characteristic  of  dementia 
praecox,  be  capable  of  being  regarded  at  least  partly  as  an 
expression  of  engrafted  hebephrenia,  modified  to  a  certain 
extent,  as  the  first  still  indefinite  action  of  the  same  morbid 
process  which  later  causes  dementia  praecox.  More  difficult 
to  explain  remains  the  fact  which,  as  it  seems,  is  also  fairly 
certain,  that  a  number  of  our  patients  exhibit  strikingly  good 
endowment.  Here  it  would  be  necessary  first  to  investigate 
how  far  it  is  a  question  of  purely  scholastic  endowment  of 
those  scholars  who  with  a  good  memory  attain  by  good 
conduct,  conscientiousness  and  indefatigable  diligence  to 
being  "  always  the  first  in  every  class."  Thus  I  remember  a 
scholar,  who  with  all  the  symptoms  of  a  hebephrenic  disposi- 
tion, shy,  lachrymose,  childish,  wholly  unboylike  conduct  and 
an  ineradicable  tendency  to  biting  his  nails,  up  to  the  highest 
class  occupied  the  position  of  a  prominent  shining  light  in 
the  school  in  consequence  of  his  exemplai:y  diligence,  which 
nothing  turned  aside.  But  further,  as  degeneration  certainly 
plays  a  part  in  the  development  of  dementia  praecox,  the 
experience  must  be  pointed  out  that  on  its  soil  not  infre- 
quently distinguished,  though  mostly  one-sided,  endowment 
is  present.  As  dementia  praecox  often  encroaches  later  and 
in  lesser  degree  on  mental  capabilities,  and  especially  on 
memory,  than  on  emotional  life  and  volition,  the  former 
might  in  certain  circumstances  still  stand  on  a  higher  level, 
while  in  the  domain  of  the  latter  already  distinct  disorders 
have  developed. 

If  we  regard  certain  predispositions  which  are  frequent  in 
the  previous  history  of  dementia  praecox  as  the  first  slight 
beginnings  of  it,  the  question  arises  further,  whether  those 
peculiarities  are  to  be  interpreted  always  in  this  sense,  and 
especially,  whether  the  onset  of  dementia  praicox  must  always 
follow  them.  The  first  question  would  only  then  be  capable 
of  an  answer,  if  the  last  must  be  answered  in  the  affirmative. 
But  of  that  there  can  obviously  be  no  dubiety.     There  are 


240  DEMENTIA   PRECOX 

without  doubt  innumerable  people  who  bear  throughout  their 
lives  features  such  as  we  have  formerly  described  without 
ever  falling  ill  mentally.  From  that  it  must  be  concluded 
either  that  other  kinds  of  inherited  or  acquired  injuries  could 
also  exercise  similar  effects  on  the  psychic  life,  or  that  in  such 
cases  the  existing  gerhi  of  dementia  pra^cox  has  not  attained 
to  further  development.  The  possibility  of  such  an  inter- 
pretation will  not  be  capable  of  dispute  in  so.  far  as  we  see 
very  slightly  defective  states  as  residuum  of  an  attack  of 
dementia  pra^cox,  which  has  been  passed  through,  persisting 
often  enough  for  decades,  to  the  end  of  life  without  further 
progress.  It  would,  therefore,  be  quite  conceivable  that 
certain  abnormal  personalities  with  the  peculiarities  men- 
tioned were  to  be  regarded  as  the  product  of  an  attack  of 
dementia  praecox  which  had  been  passed  through  in  earliest 
childhood  and  then  reached  the  close.  Bleuler  is  inclined  to 
stretch  the  limits  of  such  a  "  latent  schizophrenia "  to  an 
extraordinary  extent,  and  to  interpret  all  possible  psychopathic 
personalities  in  this  sense.  How  far  that  is  justified  in  fact 
can  scarcely  be  decided  at  present.  As  even  marked  clinical 
symptoms  do  not  always  allow  the  conclusion  to  be  made 
with  certainty  that  the  definite  morbid  process  exists,  we 
shall  probably  only  quite  exceptionally  find  the  personal 
qualities  characteristic  enough  to  discover  in  them  the 
infallible  traces  of  an  attack  of  dementia  praecox  which  has 
been  suppressed  in  its  origin. 

External  Causes. — About  the  part  which  external  causes 
might  play  in  the.  development  of  dementia  precox  there  is 
little  to  report.  That  mental  over-exertion,  which  Kahlbaum 
suggested,  and  which  is  also  held  responsible  in  part  by  Deny 
and  Roy,  cannot  be  seriously  taken  into  account,  is  already 
proved  by  the  extension  of  the  disease  in  the  country 
population  and  among  the  Malays,  Tamils,  Chinese,  peoples 
growing  up  in  the  simplest  conditions  of  life. 

The  view  expressed  by  Vigouroux  and  Naudascher  and 
supported  also  by  Bleuler,  that  infections  in  the  years  of 
development  might  have  a  causal  significance,  cannot  in  its 
indefiniteness  be  either  proved  or  disproved.  The  unmistak- 
able importance  of  the  predisposition  points,  however,  to  the 
fact  that  infectious  causes  can  scarcely  be  the  decisive  factor ; 
moreover  other  complicated  factors  must  be  assumed  to 
explain  the  after-effects  of  such  causes  continuing  for  decades. 
At  the  same  time  in  about  lo  to  1 1  per  cent,  of  my 
patients  at  Heidelberg  severe  acute  diseases  had  preceded 
the  malady,  most  frequently  typhoid  or  scarlet  fever. 
Sometimes  the  picture  of  dementia  prajcox  developed  abruptly 


FREQUENCY   AND   CAUSES  241 

during  the  bodily  disease,  so  that  at  first  an  infectious 
insanity  was  thought  of;  as  a  rule,  however,  many  years  had 
passed  before  the  appearance  of  the  psychic  disorder,  so  that 
there  could  be  no  question  of  direct  connection.  Now  and 
then  it  was  stated  that  since  the  bodily  illness  a  certain 
change  had  already  been  noticed  in  the  patient,  greater 
irritability,  a  lowering  of  mental  capability,  a  marked  liability 
to  fatigue.  We  shall  regard  with  great  doubt  the  statements 
of  Bruce,  who  considers  a  short  streptococcus  the  exciting 
cause  of  the  disease,  and  was  able  by  its  means  to  produce 
"  mental  dulness"  in  rabbits. 

Just  as  little  shall  we  be  able  to  reconcile  ourselves  with 
the  view  represented  by  Steiner  and  Potzl  that  acquired 
syphilis  could  in  certain  circumstances  bring  the  disease  to 
an  outbreak.  It  cannot  be  disputed  that  recent  syphilis  is 
often  found  in  our  patients,  but  that  is  not  to  be  wondered 
at,  as  it  has  mostly  to  do  with  young  people  in  the  third 
decade,  who  are  in  part  very  much  excited  sexually  and 
very  much  inclined  to  excesses.  In  isolated  cases  there  was 
a  report  of  inflammation  of  the  brain  in  childhood,  not 
altogether  infrequently  also  of  head-injuries}-  which,  however, 
are  in  any  case  so  frequent,  that  they  can  only  quite  excep- 
tionally be  made  use  of  for  establishing  a  cause.  Also  in 
brain  diseases,  especially  tumours,  "  catatonic "  morbid 
results  are  occ^isionally  observed  ;  but  we  cannot  doubt 
but  that  in  such  cases  apart  from  chance  coincidences  the 
resemblances  are  purely  external.  The  misuse  of  alcohijl 
appears  to  have  no  significance  for  the  origin  of  dementia 
praecox.  Though  15  to  16  per  cent,  of  the  men  observed 
by  myself  had  drunk  heavily,  as  a  rule  it  is  a  case  of 
debauches  which  are  caused  by  the  morbid  instability  and 
irregular  conduct  of  life  of  the  patients. 

The  fact  already  touched  on  is  striking,  that  the  outbreak 
of  dementia  praecox  frequently  takes  place  m  prison.  Among 
600  men  about  6  per  cent,  had  fallen  ill  in  detention,  in  jail 
or  in  the  convict-prison  ;  to  these  were  added  8  per  cent,  of 
vagrants  of  whom  likewise  a  considerable  number  had  shown 
the  first  symptoms  of  the  disorder  in  the  workhouse.  It  is 
suggestive  of  the  possibility  that  the  emotional  influences 
of  the  loss  of  freedom,  the  monotonous  food,  the  limitation 
of  movement,  the  being  shut  up  from  air  and  light,  the 
facilitation  of  onanistic  tendencies  may  be  productive  of 
disease.  In  more  exadt  investigation,  however,  it  can  be 
shown  for  a  considerable  number  of  the  cases  that  probably 
already  a  long  time  previously  changes  of  the  personality 

^  V.  Muralt,  AUgem.  Zeitschr.  f.  Psych.  Ivii.  457. 

Q 


242  DEMENTIA   PRECOX 

in  the  sense  of  dementia  pntcox  had  taken  place,  which  then 
made  the  patient  a  habitual  criminal  and  vagrant.  It  is  a 
remarkable  fact  that  by  preference  paranoid  forms  develop 
on  prepared  soil  through  the  influence  of  the  loss  of  freedom, 
so  that  these,  therefore,  at  least  give  a  characteristic  colouring 
to  the  morbid  picture.  Whether  beyond  this  in  individual 
cases  the  loss  of  freedom  can  gain  real  causal  significance 
for  dementia  prrecox  has  become  doubtful  to  me. 

Among  386  women  there  were  3  per  cent,  prostitutes. 
Once  I  saw  two  sisters  fall  ill  almost  at  the  same  time  who 
were  both  prostitutes  ;  a  respectable  young  woman,  already 
mentioned  formerly,  gave  birth  to  three  illegitimate  children 
after  recovery  from  a  state  of  severe  catatonic  excitement. 
A  woman  fell  ill  while  in  custody,  and  became  demented 
after  she  had  prostituted  herself  in  an  incredible  way,  being 
urged  to  do  so  by  her  husband,  he  being  present  hidden  in 
a  cupboard.  That  probably  the  immorality  in  all  such  cases 
is  the  consequence  and  not  the  cause  of  dementia  praecox 
scarcely  requires  more  proof     - 

We  stand  perhaps  on  a  somewhat  firmer  foundation  in 
the  consideration  of  the  relations  between  dementia  praicox 
and  the  work  of  reproduction.  Apart  from  the  fact,  that 
disorders  of  menstruation  are  frequent  and,  moreover, 
exacerbations  of  the  morbid  process  are  often  observed 
during  the  menses,  dementia  praicox  begins  in  a  considerable 
number  of  cases  during  pregnancy,  in  childbed  or  after  a 
miscarriage,  sometimes  also  first  in  the  period  of  lactation. 
In  Heidelberg  I  saw  nearly  a  fourth  of  the  catatonic  cases  in 
women  develop  in  connection  with  the  work  of  reproduction, 
while  of  the  hebephrenic  cases  not  even  in  a  tenth  could  such  a 
connection  be  recognized.  Once  the  four  attacks,  in  which 
the  disease  ran  its  course,  were  each  connected  with  a  birth, 
till  the  last  brought  the  final  dementia.  In  another  case  the 
disease  began  likewise  in  childbed  and  after  a  remission  of 
considerable  duration  ended  with  the  occurrence  of  a  fresh 
pregnancy  in  a  severe  relapse.  As,  however,  the  attacks  of 
manic-depressive  insanity  also  are  readily  connected  with  the 
changes  caused  by  the  work  of  reproduction,  it  must  remain 
for  the  present  undecided  how  far  here  it  has  to  do  with 
closer  causal  connections.  The  apparent  increase  of  the 
attacks  in  the  climacteric  also  has  to  be  remembered,  which 
would  likewise  correspond  to  the  observations  in  manic- 
depressive  insanity. 

Sexual  Life. — Meantime  the  experiences  touched  on  give 
us  the  occasion  to  examine  somewhat  more  closely  the 
behaviour  of  the-  sexual   processes   in   our   patients.     Here 


FREQUENCY   AND   CAUSES  243 

must  be  first  pointed  out  what  in  the  clinical  descriptions 
must  ever  again  be  emphasized,  that  in  our  patients  very 
frequently  a  lively  sexual  excitement  exists,  which  makes 
itself  known  in  regardless  onanism,  debauches,  and  tormenting 
sexual  ideas  of  influence.  Especially  of  male  patients  one 
learns  with  striking  frequency  that  for  many  years  they  have 
constantly  masturbated.  Formerly,  therefore  certain  morbid 
pictures  belonging  to  hebephrenia  were  simply  described  as 
the  "  insanity  of  masturbation "  ;  perhaps  also  part  of  the 
widespread  ideas  about  the  terrible  consequences  of  onanism 
is  connected  with  such  experiences.  Lastly,  it  is  worthy  of 
mention  that  often  the  outbreak  of  dementia  praecox  is 
brought  into  causal  connection  with  the  abandonment  or 
the  failure  of  a  plan  of  marriage. 

The  observations  quoted,  which  appear  to  point  to  rela- 
tions between  dementia  praecox  and  sexual  life,  have  had 
much  attention  paid  to  them.  Tschisch  has  come  to  the 
view  that  suppression  or  defective  development  of  sexual 
activity  is  to  be  regarded  as  the  cause  of  dementia  praecox, 
and  Lomer  ascribes  the  cause  to  disorders  of  the  internal 
secretion  of  the  sexual  glands.  I  also  have  expressed  the 
view  that  possibly  there  might  exist  some  or  other  more  or 
less  distant  connection  between  dementia  praecox  and  the 
processes  of  the  sexual  organs.  It  must  meantime  be  empha- 
sized that  convincing  proofs  for  such  assumptions  are  not  by 
any  means  forthcoming.  Increase  of  sexual  excitement  is 
found  in  all  possible  forms  of  insanity.  Onanism  meets  us 
also  frequently  enough  in  simple  psychopathies,  and  it  might 
be  encouraged  in  our  patients  by  their  shy  reserve  which  often 
makes  sexual  approach  impossible  for  them.  The  failure  of 
plans  of  marriage  is  probably  with  more  correctness  to  be 
regarded  as  consequence  and  not  as  cause  of  the  disease. 
But  lastly  the  considerations  brought  forward  above,  which 
point  to  a  more  frequent  reaching  back  of  the  malady  into 
childhood,  take  away  part  of  the  significance  of  its  relations 
to  sexual  development,  a  significance  which  might  be  attached 
to  these  relations,  if  the  quite  similar  behaviour  of  manic- 
depressive  insanity  is  not  taken  into  consideration. 

In  any  case  we  have  to  think  of  those  connections,  just  as 
of  those  with  pregnancy,  childbed  and  climacteric  as  very 
common.  One  could  perhaps  imagine  as  connecting  links, 
disorders  in  the  bodily  economies,  as  they  accompany  the 
great  changes  of  life  and  in  certain  circumstances  draw  after 
them  far-reaching  consequences.  Our  attention  has  been 
drawn  to  these  circumstances  mostly  by  the  better  under- 
standing of  the  disorders  of  the  thyroid  gland,  which  likewise 


244  DEMExNTIA    PRECOX 

exhibit  certain  relations  to  menstruation,  pregnancy  and 
climacteric.  The  occasional  appearance  of  increase  and 
decrease  of  the  th)'roid,  remarkable  thickening  of  the  skin, 
facial  phenomena,  acceleration  or  retardation  of  the  pulse, 
tetanoid  seizures,  brings  immediately  to  remembrance  the 
phenomena  observed  in  diseases  of  the  thyroid  gland  ;  on  the 
other  hand,  according  to  lilum's  descriptions,  the  disorders  of 
the  psychic  life  and  of  movement  in  dogs  without  a  thyroid 
gland  present  a  certain  similarity  to  the  behaviour  of  cata- 
tonic patients,  Lundborg  has  therefore  brought  dementia 
praecox  into  relationship  with  myoclonia,  myotonia  and 
tetany,  and  has  regarded  as  its  foundation  changes  in  the 
thyroid  and  parathyroids. 

Auto-intoxication. — At  present  it  is  obviously  premature 
to  form  any  opinion  at  all  about  the  possibilities  which  might 
perhaps  come  into  consideration  for  the  explanation  of  the 
points  of  agreement  indicated  ;  for  that  all  serviceable  founda- 
tions are  still  lacking.  Nevertheless,  the  general  statement 
may  perhaps  with  all  reserve  be  made,  that  a  series  of  facts 
in  dementia  praecox  up  to  a  certain  degree  makes  probable 
the  existence  of  an  auto-intoxication  in  consequence  of  a 
disorder  of  metabolism.  Many  investigators  have  found  even 
the  morbid  anatomy  similar  to  that  of  chronic  iatoxication. 
Further  Ajello  believes  that  he  is  able  to  connect  the  changes 
brought  forward  by  him  in  the  behaviour  of  the  muscles 
with  the  action  of  a  toxin  such  as  might  perhaps  correspond 
to  veratrin  ;  also  the  frequency  of  idiopathic  muscular  swell- 
ings, heightened  mechanical  excitability  of  muscles  and 
nerves,  the  increase  of  the  tendon  reflexes  could  be  inter- 
preted in  the  same  sense.  Further  evidence  could  perhaps 
be  found  in  the  statements,  certainly  still  in  need  of  more 
exact  examination,  about  blood  changes  and  metabolic  dis- 
orders. Tomaschny  has  also  interpreted  the  frequency  of 
headache  in  the  same  sense.  If  we  then  still  take  into 
consideration  the  occurrence  of  o.steomalacia  in  dementia 
praicox  emphasized  by  Barbo  and  Haberkandt,  and  lastly 
the  above-mentioned  relations  to  the  work  of  reproduction, 
the  indications  appearing  here  and  there  of  thyroid  symptoms, 
the  great  fluctuations  of  the  body-weight,  with  shapeless 
adiposity  on  the  one  hand,  and  the  most  extreme  emaciation 
on  the  other,  the  occasional  great  fall  of  temperature,  the 
epileptiform  seizures,  and  the  cases  of  sudden  death,  the 
conclusion  is  on  the  whole  justified,  that  according  to  the 
present  position  of  our  knowledge  the  assumption  of  an  auto- 
intoxication, which  sometimes  develops  insidiously,  some- 
times sets  in  violently,  has  for  itself  the  greatest  probability. 


FREQUENCY   AND   CAUSES  245 

About  the  source  and  kind  of  the  toxin  circulating  in  the 
body,  we  can  certainly  at  present  give  just  as  little  account 
as  in  the  metasyphilitic  or  metalcoholic  diseases  which  in 
their  causes  are  already  much  better  explained. 

Against  this  view  it  must  be  said  that  those  observations 
appear  at  first  to  give  evidence  which  point  to  a  causal 
importance  of  the  inherited  or  at  least  congenital  pre- 
disposition. The  view  has  often  been  brought  forward,  that 
hebephrenic  dementia  signifies  nothing  else  than  the  gradual 
failure  of  an  inadequate  constitution.  Like  a  tree  whose 
roots  find  no  more  nourishment  in  the  soil  at  their  disposal, 
so  the  mental  powers  are  said  to  disappear  as  soon  as  the 
insufficient  dowry  no  longer  allows  a  further  unfolding.  Pick 
speaks  of  a  "  failure  of  the  vital  capacity  of  the  brain,"  of  a 
"  disproportion  between  efficiency  and  work."  So  enticing  as 
this  interpretation  appears  to  be  at  the  first  glance,  especially 
for  the  insidiously  progressive  inadequacy  of  dementia 
simplex  and  the  forms  similar  to  it,  just  as  little  nevertheless 
can  it  stand  more  exact  examination.  Already  there  is 
difficulty  in  understanding  why  the  development  of  the 
patients  without  recognizable  external  cause  should  not  only 
stop  short  all  at  once,  but  should  directly  end  in  profound 
psychic  decline.  To  that  must  be  added  that  the  change, 
though  it  usually  appears  after  all  sorts  of  premonitory 
symptoms,  still  not  infrequently  occurs  rather  suddenly,  that 
then  again  improvement  lasting  for  years,  indeed  more  or 
less  complete  recoveries,  may  occur  after  very  severe  morbid 
phenomena,  all  of  these  being  circumstances  which  can 
scarcely  be  explained  from  the  standpoint  described.  But  in 
any  case  the  fact  is  decisive,  that  the  morbid  anatomy  has 
disclosed  not  simple  inadequacy  of  the  nervous  constitution, 
but  destructive  morbid  processes,  as  the  background  of  the 
clinical  picture. 

But  neither  from  the  clinical  standpoint  is  there  any 
ground  for  regarding  dementia  prjecox  as  the  direct 
expression  of  a  particularly  severe  degeneration.  The  part, 
which  must  be  allocated  here  to  the  familial  disposition,  is 
rather  smaller  than  in  the  pronounced  forms  of  the  insanity 
of  degeneration,  in  manic-depressive  attacks,  in  hysteria,  and 
in  psychopathy.  Nevertheless  we  invariably  meet  there  not 
the  tendency  to  dementia,  but  rather  morbid  states  filling  the 
whole  life  uniformly  or  in  periodic  return  without  rapid 
progress.  By  these  considerations  dementia  praecox  comes 
nearer  to  epilepsy  ;  in  it  also,  besides  the  undeniable  import- 
ance of  the  inherited,  or  early  acquired,  constitution,  we  have 
cause   to  assume   the    development   of  definite,   destructive 


246  DEMENTIA    PR/ECOX 

morbid  processes  progressing  either  somewhat  slowly  or 
rather  rapidly,  which  sometimes  reach  back  into  childhood, 
sometimes  begin,  or  at  least  experience  an  exacerbation, 
about  the  time  of  sexual  maturitj'.  There  also  we  come 
across  facts  which  make  the  existence  of  disorders  of 
metabolism  in  high  degree  probable  ;  epilepsy  also  is  a  very 
ancient  disease  and  spread  over  the  whole  world.  If  one  will, 
one  may  to  the  further  understanding  of  the  relations  between 
constitution  and  disease  bring  into  the  discussion  certain 
frequent  disorders  of  metabolism  with  purely  bodily  abnor- 
malities, diabetes,  gout,  chlorosis,  the  occurrence  of  which  is 
undoubtedly  essentially  favoured  by  inborn  peculiarity. 

Freudian  Complexes. — The  adherents  of  F^reud's  psycho- 
logy of  complexes  have  gone  their  own  way  in  the  view 
which  they  take  of  dementia  precox,  as  in  many  other 
clinical  questions.  Bleuler  and  Jung^  have  first  brought 
forward  the  opinion,  that  "  complexes,"  groups  of  ideas 
strongly  emphasized  by  emotion,  are  to  be  regarded  as  the 
causes  of  the  morbid  phenomena  or  at  least  of  their  appear- 
ance, complexes  which  here  on  morbid  soil  can  give  rise 
to  specially  momentous  effects.  They  are  said  to  exercise 
a  far-reaching  influence  on  thought  and  action  and,  according 
to  Jung's  expression,  are  able  to  rob  the  ego  of  light  and 
air,  as  cancer  takes  the  vital  power  from  the  body.  In 
support  of  these  assertions  the  experience  is  brought  forward, 
that  psychic  causes  frequently  bring  about  improvement  or 
aggravation  in  the  state  of  the  patients,  and  that  many 
patients  for  a  considerable  time  give  utterance  to  ideas 
which  are  in  connection  with  events  of  life  emphasized  by 
emotion.  The  former  statement  is  in  general  correct  and 
indeed  self-evident,  but  is  subject  in  detail  to  very  many 
exceptions.  If  the  latter  statement  were  not  true,  here  also, 
as  in  the  most  varied  mental  disorders  of  a  different  kind, 
it  would  certainly  be  wonderful.  But  I  think  from  an 
experience  sufficient  for  this  question  that  I  may  conclude 
that  it  is  far  more  rare  than  might  be  expected  according 
to  general  psychological  laws,  or  than  we  observe  it  to  be  in 
many  other  forms  of  insanit)-.  What  has  bewildered  me 
ever  afresh  innumerable  times,  was  just  the  complete  failure 
of  the  most  natural  complexes  emphasized  by  emotion  of 
healthy  life.  One  may  here  certainly  find  the  assumption 
helpful,  that  it  is  a  case  of  suppressed  and  transformed  ideas, 
of  "  masks,"  the  real  meaning  of  which  can  only  be  guessed 
by  an   interpretation,  dependent  on  the  fine  feeling  of  the 

'  Jung,  L'ber  die  I'sychologie  der  Dementia  pnvcox.  1907  ;  Isserlin, 
Centralhl.  f.  Nervenheilk.  u.  I'sychiatrie.  1907,  329. 


FREQUENCY   AND  CAUSES  247 

observer,  of  association  experiments  and  dreams,  a  proceed- 
ing which,  judging  by  the  examples  forthcoming,  has  little 
attraction  for  me.  But  if  by  complexes  nothing  else  is 
meant  than  delusions,  in  which  the  fears  and  wishes  of  the 
patients  are  reflected,  that  would  be  only  a  new  and,  as  it 
appears  to  me,  a  not  exactly  desirable  expression  for  an  old 
thing.  Its  danger  lies  in  the  psychological  views  from  which 
it  proceeds.  The  idea  of  independent,  parasitic  psychic 
neoplasms,  which  on  the  one  hand  are  completely  withdrawn 
from  the  influence  of  the  ego,  but  on  the  other  hand  are  able 
wholly  to  transform  and  almost  annihilate  it,  would  overthrow 
such  a  number  of  everyday  and  thoroughly  ascertained 
psychological  experiences,  that  its  substantiation  must  in 
any  case  be  supported  by  quite  other  means  of  proof  than 
has  hitherto  been  the  case. 

The  opinion,  that  a  large  part  of  the  clinical  morbid 
picture  can  be  explained  by  the  effect  of  complexes,  has  then 
further  led  to  the  differentiation  of  primary  and  secondary 
symptoms.  Only  the  former  are  said  to  represent  the 
immediate  expression  of  the  destructive  morbid  process, 
while  the  latter  proceed  from  the  reaction  to  the  influences  of 
the  surroundings  and  to  the  morbid  efforts  of  the  patients 
themselves.  Thus  according  to  Riklin  negativism  is  said  to 
depend  on  inhibitions  by  the  action  of  complexes ;  also  the 
mistaking  of  persons,  delusions,  nonsensical  answers,  persever- 
ation, catalepsy,  are  connected  with  complexes,  which 
furthermore  hinder  suitable  adaptation  to  surroundings.  All 
those  expressions  of  morbidity  are  said  to  be  just  as 
comprehensible  psychologically  under  the  now  existing 
hypotheses  created  by  the  disease  as,  according  to  Freud's 
explanations,  dreams  are,  as  soon  as  one  has  learned  to 
interpret  their  intricate  and  extremely  arbitrary  symbolism. 
Jung  even  gave  utterance  to  the  sentence :  "  If  we  let  an 
individual  who  is  dreaming  go  about  and  act  as  if  he  were 
awake,  we  have  the  clinical  picture  of  dementia  praecox." 
Even  though  it  were  admitted  that  in  the  domain  of  thought 
and  of  speech-expression  similarities  exist  between  dreaming 
and  dementia  praecox,  that  statement  is  for  the  rest  so 
evidently  untenable,  that  a  refutation  appears  the  more 
superfluous  as  every  proof  at  all  acceptable  is  lacking. 

The  separation  of  the  morbid  phenomena  into  primary 
and  secondary  I  consider  purely  artificial.  It  certainly 
cannot  be  disputed  that  in  our  patients  some  domains  of  the 
psychic  life  are  less  injured  than  others  and  that  many  of 
their  trains  of  thought,  utterances  and  actions  would  be  more 
comprehensible  to  us,  if  we  knew  their  hypotheses,  but  the 


248  DEMENTIA   PR.«COX 

wheelwork  of  our  soul  is  so  compactly  fitted  each  part  to  the 
other,  and  the  anatomical  morbid  process  is  moreover  so 
widespread,  that  a  division  according  to  direct  or  indirect 
causation  of  the  morbid  phenomena  appears  to  me  on  this 
account  to  be  quite  impossible.  In  any  case  the  attempts, 
which  up  to  now  have  been  made  in  this  direction,  are  not  at 
all  convincing. 

The  distinction  made  by  Bleuler  o{ fundauiental  disorders 
and  accompanying  phenomena  of  the  disease  is  to  be  judged 
essentially  otherwise.  The  former  constitute  the  real 
characteristic  of  the  clinical  state  and  can  be  demonstrated 
in  each  individual  case  more  or  less  distinctly  ;  the  latter 
may  be  present,  but  may  also  be  absent ;  they  are  not  caused 
by  the  character  of  the  morbid  process  but  by  circumstances 
which  are  in  loose  connection  with  it.  Those  must  therefore 
be  regarded  as  fundamental  disorders,  which  meet  us  in  the 
picture  of  dementia  simplex  and  in  the  terminal  state  called 
simple  weak-mindedness,  while  all  the  remaining  morbid 
symptoms  represent  obviously  not  necessary,  though  in  part 
very  common,  accompanying  phenomena  of  the  disease. 
From  this  point  of  view  the  weakening  of  judgment,  of 
mental  activity  and  of  creative  ability,  the  dulling  of 
emotional  interest  and  the  loss  of  energy,  lastly,  the  loosening  of 
the  inner  unity  of  the  psychic  life  would  have  to  be  reckoned 
among  the  fundamental  disorders  of  dementia  prsecox,  while 
all  the  remaining  morbid  symptoms,  especially  hallucinations 
and  delusions,  but  also  the  states  of  excitement,  depression 
and  stupor,  further  the  manifold  disorders  of  volition, 
negativism,  automatic  obedience,  stereotypy,  mannerisms, 
impulsive  actions,  would  be  regarded  more  as  secondary 
accompanying  phenomena.  Bleuler  reckons  "ambivalence  " 
and  "  autism "  also  among  the  fundamental  disorders,  not, 
however,  as  appears  to  me,  altogether  with  right,  as  there  are 
terminal  states  in  dementia  prsecox,  in  which  these  abnor- 
malities are  lacking,  while  the  above-mentioned  fundamental 
disorders  are  present. 

By  what  circumstances  the  appearance  in  the  clinical 
picture  of  the  secondary  phenomena  mentioned  is  caused,  is 
at  present  unknown.  Paralysis  will  be  called  to  mind  here, 
where  likewise,  the  simple,  characteristic  dementia,  which  is 
the  rule  in  the  childish  paralytic,  may  be  elaborated  by 
delusions,  states  of  excitement,  ill  -  humour  and  so  on. 
Differences  in  the  course  and  in  the  local  extension  of  the 
morbid  process  might  not  be  without  significance.  The 
forms  which  develop  insidiously  usually  bear  the  stamp  in 
paralysis,  as  in  dementia  praecox,  of  a  simple,  progressive 


FREQUENCY   AND   CAUSES  249 

weak-mindedness,  and  those,  which  have  a  violent  onset,  that 
of  states  of  excitement  and  confusion  with  vivid  delusions. 
Lastly,  for  the  form  of  the  clinical  picture  the  circumstance 
might  not  be  without  significance,  that  according  to  the 
development  of  the  psychic  personality  the  morbid  process 
must  injure  sometimes  these,  sometimes  those  faculties  of  the 
brain  in  a  more  striking  way.  I  do  not  think  here  of  the 
effect  of  complexes  which  have  been  acquired  by  chance 
and  have  become  psychic  parasites,  but  of  the  very  varied 
consequences,  which  a  change  in  the  brain  must  have 
according  to  the  particular  direction,  in  which  the  faculties  of 
the  individual  complicated  brain  machine  and  in  especial  of 
the  injured  parts  have  been  fashioned  by  life.  Thus  the 
rarity  observed  by  myself  of  hallucinations  of  hearing  in 
the  Javanese  patients  might  be  explained  by  the  slighter 
significance  which  speech  ideas  have  there  for  thought ;  thus 
we  have  seen  that  with  progressive  development  and  rigidity 
of  the  psychic  personality  the  delusions  usually  become  more 
connected  and  more  systematized.  It  would  also  well  be 
conceivable  that  for  the  form  of  the  peculiar  catatonic 
disorders  of  volition  besides  the  kind  and  extent  of  the 
morbid  changes,  the  special  volitional  constitution  might  be 
of  importance  ;  I  found  it  striking  that  the  disorders  mentioned 
seemed  to  be  less  pronounced  in  the  Javanese  patients  than 
with  us. 

While  Bleuler  ascribes  significance  to  complexes  and  in 
general  to  psychological  influences  only  for  the  form  of  the 
clinical  condition,  Jung  claims  them  in  certain  circumstances 
also  as  a  real  cause  of  the  disease.  The  complex  emphasized 
by  affect  is  thus  said  to  be  able  to  act  as  the  starting-point 
of  the  disease  in  a  way  similar  to  that  of  a  trauma  or  an 
infection.  That  might  be  conceded  in  so  far  as  the  origin 
of  an  attack  of  dementia  praecox  by  trauma  or  infection  is 
just  as  unproved  as  by  complexes.  But  Jung  gets  a  con- 
nection here  with  the  theory  of  intoxication  by  pointing 
out  the  possibility  of  the  emotion  being  able  to  produce  a 
kind  of  toxin,  as  it  otherwise  might  well  arise  of  itself  and 
might  cause  the  disease.  Surely  then  it  would  not  be  under- 
stood why  the  manic-depressive  patients  with  their  violent 
emotions  do  not  produce  the  destructive  toxins  which  lead 
to  dementia  in  the  greatest  quantity  ! 

Abraham  has  taken  the  Freudian  doctrines  into  the  service 
of  dementia  praicox  more  on  the  sexual  side.  For  him  the 
malady  signifies  the  "auto-erotic"  disposition,  existing  from 
youth  up,  the  incapacity  for  objective  love,  which  produces 
in    its    own    time   the   withdrawal    from    the   surroundings, 


250  DEMENTIA   PRyECOX 

especially  the  aversion  to  the  parents  formerly*  involved  in 
erotic  relations,  as  well  as  the  ideas  of  persecution,  further 
the  tendency  to  onanism  and,  by  the  transference  of  sexual 
overestimation  to  the  patient's  self,  megalomania.  The 
persecutors  are  frequently  people  the  patient  has  formerly 
loved  ;  the  hallucinations  always  concern  the  complex. 
Another  series  of  similar  "  analyses "  of  the  mental  state 
in  dementia  praicox  has  come  from  the  Zurich  School.  They 
all  run  in  the  direction  of  gaining  an  understanding  of  the 
deeper  sense  which  is  hidden  behind  the  "  mask "  of  the 
confused  talk  and  incomprehensible  actions  of  the  patients. 
"  Freud  and  Jung  have  shown  that  the  system  of  delusions 
of  the  patients  is  not  in  the  least  nonsensical,  but  follows 
the  same  laws  as  perhaps  a  dream,  which  always  discloses 
itself  as  a  sensual  elaboration  of  a  complex,"  is  what  is  said. 
But  the  complexes  are  as  good  as  without  exception  sexual. 

Here  we  meet  everywhere  the  characteristic  fundamental 
■features  of  the  Freudian  trend  of  investigation,  the  repre- 
sentation of  arbitrary  assumptions  and  conjectures  as  assured 
facts,  which  are  used  without  hesitation  for  the  building  up 
of  always  new  castles  in  the  air  ever  towering  higher,  and 
the  tendency  to  generalization  beyond  measure  from  single 
observations.  I  must  frankly  confess  that  with  the  best 
will  I  am  not  able  to  follow  the  trains  of  thought  of  this 
"  metapsychiatry,"  which  like  a  complex  sucks  up  the  sober 
method  of  clinical  observation.  As  I  am  accustomed  to 
walk  on  the  sure  foundation  of  direct  experience,  my 
Philistine  conscience  of  natural  science  stumbles  at  every 
step  on  objections,  considerations  and  doubts,  over  which 
the  lightly  soaring  power  of  imagination  of  Freud's  disciples 
carries  them  without  difficulty.  I  also  hold  the  view  that 
many  speeches  and  actions  of  our  patients  are  not  so  non- 
sensical as  they  appear  to  us  and  that  sexual  emotions 
certainly  play  a  considerable  part  in  them.  But  as  I  only 
succeed  very  exceptionally  in  explaining  rriy  own  dreams 
to  a  certain  extent,  although  the  preliminary  conditions  are 
certainly  as  favourable  for  that  as  possible,  I  must  not  only 
say  explicitly  that  the  statement,  that  a  dream  "  always 
discloses  itself  as  a  sensuous  elaboration  of  a  complex,"  is 
wholly  imaginary,  but  I  am  also  unable  to  pluck  up  courage 
to  give  any  credence  to  the  disclosures  which  are  yielded 
by  the  "analysis"  of  the  processes  of  consciousness  of  our 
patients  which  are  infinitely  more  difficult  to  understand, 
Certainly  anyone  who  can  decide  to  regard  the  utterances 
of  the  patients  sometimes  literally,  sometimes  as  the 
expression  of  the  contrary,  sometimes  again  as  "  symbols  " 


FREQUENCY   AND   CAUSES  251 

of  any  other  ideas  whatever,  who  in  all  these  expulsions, 
displacements,  concealments,  finds  his  way  with  confidence, 
will  not  find  it  too  difficult  in  the  end  to  discover  in  a  fable 
ofGellert  a  background  of  secret  incestuous  thoughts,  jealous, 
masochistic,  sadistic  or  homosexual  emotions. 


•    CHAPTER  X. 
DELIMITATION. 

Whether  dementia  praccox  in  the  extent  here  delimited 
represents  one  uniform  disease^  cannot  be  decided  at  present 
with  certainty.  In  any  case  we  shall  no  longer  need  to 
refute  in  detail  the  objection  formerly  brought  from  different 
sides  against  the  establishment  of  the  morbid  form,  that  it 
was  a  case  of  unjustified  grouping  of  uncured  psychoses  of 
very  different  kinds,  of  melancholia,  mania,  acute  and  chronic 
confusion,  derangement.  Clinical  experience  has  demon- 
strated innumerable  times  that  it  is  possible  from  the 
conception  of  the  pathology  of  dementia  precox  to  foretell 
with  great  probability  the  further  course  and  the  issue  of  a 
case  belonging  to  the  group  ;  but  in  saying  that,  the  proof  is 
furnished  that  our  picture  of  dementia  praecox  is  in  the  main 
agreeable  to  natural  laws.  Nevertheless,  it  is  certainly 
possible  that  its  borders  are  drawn  at  present  in  many 
directions  too  narrow,  in  others  perhaps  too  wide. 

Paranoid  Forms. — The  most  criticism  has  always  been 
directed  against  the  inclusion  of  the  paranoid  forms  in 
dementia  precox.  It  cannot  be  denied  that  the  pictures  of 
paranoid  states  at  first  sight  do  not  have  the  slightest 
resemblance  to  those  of  catatonic  stupor,  of  excitement  or 
of  dementia  simplex.  Meantime  the  diversity  among  one 
another  of  the  pictures  described,  as  also  all  similar  experi- 
ences in  other  diseases,  such  as  in  paralysis,  in  cerebral 
syphilis,  in  manic-depressive  insanity,  point  to  the  fact  that 
it  is  very  hazardous  to  draw  conclusions  from  the  clinical 
states  alone  as  to  whether  they  belong  to  the  same  or 
to  different  forms  of  disease.  This  question  can  only  be 
decided  by  the  whole  course  of  the  malady,  and  the 
appearance,  gradually  becoming  always  more  distinct,  of 
those  morbid  symptoms  which  are  essential  to  the  disease  as 
opposed  to  the  more  secondary,  though  often  much  more 
striking,  accompanying  phenomena. 

If  we  apply  these  principles  to  the  case  before  us,  the 
result  is  that  at  least  some  of  the  attacks  beginning  in 
paranoid  form,  as  before  described,  issue  in  quite  the  same 


DELIMITATION  253 

terminal  states  as  the  remaining  forms  of  dementia  praecox. 
The  delusions,  which  originally  completely  dominated  the 
morbid  picture  for  years,  may  vanish  leaving  scarcely  a  trace, 
may  be  corrected  by  the  patient,  denied  or  forgotten,  while 
a  simple  hebephrenic  weak-mindedness  remains.  In  other 
cases  again  there  are,  interpolated  in  a  paranoid  morbid 
course,  states  which  bear  unmistakably  the  stamp  of  dementia 
praecox,  silly  excitement  with  mannerisms  and  stereotypies 
or  negativistic  stupor.  Fuchs  has  described  a  case  in  which 
between  two  such  acute  attacks  for  more  than  ten  years  a 
purely  paranoid  state  was  present.  Lastly,  it  must  be 
pointed  out  that  delusions  and  hallucinations  of  quite  the 
same  kind,  as  we  see  them  in  paranoid  cases,  occur  also  in 
most  of  the  remaining  forms  of  dementia  praecox,  certainly 
here  in  connection  with  a  series  of  other  morbid  symptoms. 
The  changing  composition  of  the  morbid  pictures  in  a  given 
group  of  phenomena  with  sometimes  weaker,  sometimes 
stronger  characterization  of  single  features  is,  however,  quite 
familiar  to  us  from  the  most  different  clinical  groups  of 
forms ;  we  shall  therefore  not  lay  too  much  stress  on  the 
occasional  absence  or  more  striking  appearance  of  single 
characteristics  for  the  clinical  judgment  of  the  states,  and  all 
the  less  if  we  see  their  composition  repeatedly  change  in  one 
and  the  same  case  of  disease. 

In  any  case  we  may,  as  I  think,  regard  it  as  certain  that 
paranoid  states  may  appear  in  the  course  of  dementia 
prsecox.  The  question  is  much  more  difficult  to  answer, 
how  wide  the  circle  of  paranoid  cases  must  be  drawn,  which 
we  are  justified  in  regarding  as  expressions  of  that  disease. 
Although  it  appears  to  me  to  be  impossible  at  present  to 
arrive  at  a  definite  conclusion  on  this  point,  nevertheless  I 
have  thought,  with  reference  to  the  doubt  which  I  expressed 
before,  that  I  should  attempt  to  make  a  narrower  delimita- 
tion. Accordingly  I  have  for  the  present  separated  from 
dementia  praecox  a  part  of  Magnan's  "  delire  chronique  "  and 
what  was  formerly  called  dementia  paranoides,  now  named 
"  dementia  phantastica."  On  the  other  hand  I  have  still 
included  in  dementia  praecox  those  paranoid  forms  which 
pass  with  comparative  rapidity  into  marked  psychic  decline 
and  in  which,  besides  delusions  and  hallucinations,  those  dis- 
orders of  emotional  life  and  volitional  activity  can  be  demon- 
strated in  more  or  less  distinct  form,  which  meet  us  so 
invariably  in  the  disease  named.  It  is  proved,  as  far  as  I 
can  see,  to  be  wholly  impossible  to  delimit  them  sharply 
in  any  way  from  the  first-mentioned  paranoid  form.  Certainly 
the  grouping  which  is  now  attempted  is  not  final  ;  but  at 


254  DEMENTIA    PRECOX 

present  we  still  wholly  lack  the  hypotheses  for  a  satisfactory 
solution  of  the  task  here  before  us. 

Catatonia. — For  several  other  groups  of  cases  also  the 
separation  from  dementia  prajcox  has  been  recommended. 
Tschisch  has  emphasized  that  catatonia  and  dementia 
praecox  are  fundamentally  different  from  each  other,  and 
Morselli^  also  has  come  to  the  conclusion,  that  catatonia 
deserves  a  place  to  itself;  it  is  curable,  and  is  caused  by 
infections.  According  to  my  observations  I  must  consider 
these  views  erroneous  or  at  least  wholly  unproven.  Even 
though  after  infectious  diseases  morbid  pictures  similar  to 
catatonia  come  under  observation,  they  can  still  not  be 
grouped  together  with  the  very  great  majority  of  cases  in 
which  such  causation  can  be  easily  established.  Whether 
catatonic  cases  may  be  cured  under  certain  circumstances, 
was  formerly  investigated  in  detail ;  as  a  rule,  however,  they 
are  not  cured.  Catatonic  states  may  further  appear  suddenly 
in  each  period  of  dementia  praicox,  sometimes  only  after 
a  decade.  Then  we  observe  after  catatonias  exactly  the 
same  terminal  states  as  in  the  remaining  forms  of  dementia 
praicox ;  but  lastly,  the  "  catatonic "  symptoms  may  be 
present  in  the  morbid  picture  in  all  possible  grades  and 
groupings.  I  see,  therefore,  no  possibility  of  attaining  with 
their  help  to  a  delimitation  of  an  independent  clinical  form. 

Meeus  has  proposed  to  delimit  a  hebephrenic-catatonic 
group  from  the  paranoid  forms  and  from  dementia  simplex. 
I  think,  however,  that  we  need  not  recognize  this  as  a 
separate  disease.  It  represents,  strictly  speaking,  the  previous 
history  of  numerous  cases  of  dementia  praecox,  in  which  a 
fuller  development  of  the  clinical  picture  takes  place  later. 
If  one  will,  one  may  place  the  slighter  cases  alongside  the 
^'  formes  frustes,"  as  they  are  described  by  the  French  in 
morbid  pictures  of  another  kind,  the  forms  with  poorly 
developed  disorders,  while  the  more  severe  would  be  com- 
pared with  perhaps  the  simply  demented  paralysis.  As 
numerous  cases,  beginning  first  as  dementia  simplex,  later 
follow  the  ordinary  course  of  dementia  pra;cox,  we  have  to  do, 
as  Diem  also  has  already  emphasized,  with  indefinite  bound- 
aries. Nor  can  I  make  up  my  mind  to  make  a  special  place, 
as  Vogt  proposes,  for  dementia  infantilis.  It  will  have  to  be 
admitted  that  the  conception  of  the  disease  has  hitherto  been 
insufficiently  elucidated,  and  that  therefore  among  the  so- 
called  cases  all  sorts  of  component  parts  of  various  kinds 
may  be  found.  Nevertheless  the  picture  described  appears 
to  me  to  correspond  so  completely  with  the  dementia  praicox 
'  MorKlli,  Rivista  di  freniatria  sperimentale  xxsiv.  3. 


DELIMITATION  255 

of  adults,  that  we  may  without  hesitation  ascribe  to  it  the 
majority  of  the  cases  with  the  proviso  of  the  ,  rejection  of 
extraneous  admixtures,  as  the  assumption  of  a  dementia 
praecox  in  childhood  can  present  no  difficulty  to  us  now. 

Psycho-reaction. — An  extremely  convenient  solutionof  all 
these  questions  of  delimitation  seemed  to  be  offered  by  the 
"  psycho-reaction  "  brought  forward  by  Much  and  Holzmann. 
It  was  a  question  of  the  inhibition  in  the  presence  of  the 
serum  of  certain  mental  patients  of  the  lysis  of  human  red 
blood  corpuscles  effected  by  cobra  poison.  As  this  inhibiting 
effect  was  said  only  to  belong  to  the  serum  of  patients  with 
dementia  praecox  or  manic-depressive  insanity,  it  would  have 
furnished  us  with  a  valuable  aid  for  establishing  whether 
definite  morbid  pictures  belong  to  one  of  those  two  great 
forms,  and  therewith  also  to  the  distinguishing  of  independent 
groups.  If  meantime  the  fact  that  the  psycho-reaction  is 
common  to  two  groups  of  forms,  which  certainly  are  not 
nearly  related  clinically,  had  not  aroused  very  grave  doubts 
as  to  its  reliability,  further  investigation  has  given  the  result, 
that  there  can  at  present  be  no  talk  of  a  diagnostic  peculiarity 
in  that  kind  of  reaction,  but  that  it  much  rather  sometimes 
■  appears,  sometimes  fails,  in  morbid  states  of  the  most  various 
kinds,  and  also  in  healthy  individuals,  just  as  in  the  forms 
named. 

Clinical  Experience. — We  have  therefore  even  yet  to 
rely  purely  on  the  valuation  of  clinical  experience.  The 
result  is,  as  it  appears  to  "me,  that  we  are  with  great  proba- 
bility justified  in  connecting  the  great  majority  of  the  cases  up 
to  the  present  brought  together  under  the  name  of  dementia 
prcccox  with  the  same  morbid  process,  and  therefore  in  re- 
garding it  as  a  single  form  of  disease.  Everywhere  the  same 
fjindaniental  disorders  return  again,  the  loss  of  inner  unity  in 
thinking,  feeling,  and  acting,  the  dulling  of  higher  emotions, 
the  manifold  and  peculiar  disorders  of  volition  with  the  con- 
nected delusions  of  psychic  constraint  and  influence,  lastly 
the  decay  of  the  personality  with  comparatively  slight 
damage  to  acquired  knowledge  and  subordinate  expertness. 
These  features  are  certainly  not  all  demonstrable  with  full 
cld'arness  in  each  individual  case.  But  still  the  general  view 
over  a  great  number  of  complete  observations  teaches  that 
nowhere  can  a  state  be  discovered  which  is  not  connected 
by  imperceptible  transitions  with  all  the  others. 

In  any  case  the  differences  in  the  individual  clinical  cases, 

•  as  soon  as  their  whole  development  is  taken  into  account, 

seem  to  me  to  be  not  greater  than  possibly  in  paralysis.     If 

one  will,  one  may  even  in  the  appearance  of  simple  demented, 


256  DEMENTIA    PR.'ECOX 

expansive,  depressive,  stuporous,  galloping,  and  stationary 
varieties  of  the  course,  with  or  without  remissions,  as  also  of 
juvenile  cases  of  a  peculiar  form,  recognize  a  certain  general 
agreement  in  the  principal  clinical  features  of  the  two 
diseases.  As  the  delimitation  of  paralysis  is  now  assured, 
the  objections  drawn  from  the  difference  of  the  states  to  the 
view  of  dementia  praecox  as  a  unity  would  be  thereby 
weakened.  We  certainly  miss  in  paralysis  the  real  paranoid 
forms,  but  instead  we  find  them  again  in  cerebral  syphilis, 
the  clinical  forms  of  which  have  a  still  greater  multiplicity  to 
show. 

If  we  may,  therefore,  also  regard  the  essential  outlines  of 
dementia  pr?ecox  as  assured,  one  must  reckon  with  the 
possibility,  indeed  the  probability,  that  progressive  knowledge 
will  yet  bring  us  all  kinds  of  rectifications  of  the  limits  of  the 
disease.  The  giving  a  place  to  the  childish  forms  of  the 
malady,  which  certainly  requires  further  investigation, 
signifies  material  progress  also  with  regard  to  our  ^etiological 
views.  Perhaps  also  the  very  desirable  clearing  up  of  the 
doctrine  of  the  "late  catatonias"  will  bring  us  a  further 
increase  of  forms.  On  the  other  hand  again  perhaps  some  of 
the  smaller  groups  will  in  course  of  time  be  got  rid  of;  I 
think  first  of  this  possibility  namely  for  the  cases  with 
confusion  of  speech  and  those  with  2l  periodic  course. 

The  hypothesis  has  also  frequently  been  brought  forward 
that  a  morbid  process  other  than  dementia  may  be  the 
foundation  of  the  apparently  cured  cases.  I  will  not  dispute 
this  possibility.  Partly  it  will  certainly  be  a  simple  mistake 
in  diagnosis  mostly  to  the  loss  of  manic-depressive  insanity. 
But  there  might  well  be  also  other  curable  forms  of  disease  of 
different  kinds  with  phenomena  like  catatonia,  which  we  at 
present  are  not  yet  in  a  position  to  distinguish  from  dementia 
praecox.  Those  cases  with  simple  persistence  of  hallucina- 
tions without  decay  of  the  personality  might  also  come  under 
consideration.  It  must,  however,  be  recognized  that  urgent 
reasons  for  the  separation  of  the  cases,  which  do  not  go  on  to 
dementia,  are  as  yet  absent.  The  assumption,  that  the 
morbid  process  of  dementia  precox,  according  to  its  severity 
and  according  to  its  extent,  may  not  only  produce  phenome'na 
of  loss  of  different  kinds,  but  also  sometimes  issue  in 
recovery,  sometimes  lead  to  more  or  less  profound  dementia, 
is  in  itself  not  improbable.  Certainly  we  shall  cherish  the 
eager  wish  to  become  clear  as  soon  as  it  is  at  all  possible,  as 
to  which  way  it  will  take. 


CHAPTER  XI. 
DIAGNOSIS. 

The  diagnosis  of  individual  cases  of  dementia  praecox  has 
to  distinguish  the  manifold  states  from  a  whole  series  of 
diseases  which  outwardly  are  similar  but  which  are  totally 
different  in  their  course  and  issue.  Unfortunately  there  is  in 
the  domain  of  psychic  disorders  no  single  morbid  symptom 
which  is  thoroughly  characteristic  of  a  definite  malady. 
Much  rather  each  single  feature  of  the  morbid  state  may  in 
like,  or  at  least  very  similar  form,  also  make  at  a  time  the 
impression  of  an  essentially  different  morbid  process  in 
which  exactly  the  same  areas  are  involved.  On  the  other  hand 
we  may  expect  that  the  composition  of  the  entire pictui-e  made 
up  of  its  various  individual  features,  and  especially  also  the 
changes  which  it  undergoes  in  the  course  of  the  disease,  could 
scarcely  be  produced  in  exactly  the  same  way  by  diseases  of 
a  wholly  different  kind  ;  at  this  or  at  that  point,  sooner  or 
later,  deviations  will  be  certain  to  appear,  consideration  of 
which  makes  possible  for  us  the  distinguishing  of  the  morbid 
forms.  It  may  in  certain  circumstances  be  very  difficult,  not 
only  to  judge  correctly  of  the  diagnostic  significance  of  such 
deviations,  but  even  to  recognize  their  very  existence. 

Catatonic  Symptoms. —  Special  importance  in  the  estab- 
lishing of  dementia  praicox  has,  not  without  justification, 
been  attributed  to  the  demonstration  of  the  so  -  called 
"  catatonic "  morbid  symptoms.  Under  this  term  must 
principally  be  understood  the  volitional  disorders  first 
described  by  Kahlbaum  as  accompanying  phenomena  of 
catatonia,  automatic  obedience,  negativism,  mannerisms, 
stereotypies,  impulsive  actions.  As  undeniable  as  it  is,  that 
all  these  disorders  in  no  other  disease  come  under  observa- 
tion in  such  extent  and  multiplicity  as  in  dementia  praecox, 
just  as  little,  however,  may  the  appearance  of  one,  or  even 
of  several,  of  these  disorders  be  regarded  as  infallible  proof 
of  the  presence  of  that  malady.  Certainly  this  restriction 
holds  good  in  very  different  degree  for  the  individual 
disorders.  Automatic  obedience,  which  represents  only  a 
sign  of  the  surrender  of  the  patient's  own  volition,  is  found 

R 


258  DEMENTIA   PRECOX 

in  a  large  series  of  morbid  states  of  the  most  dififerent  kinds, 
and  possesses  therefore  only  very  slight  diagnostic  significance. 
Impulsive  actions  and  stereotypies  come  under  observation 
in  severe  brain  diseases,  specially  in  paralysis,  in  infectious 
psychoses,  in  senile  dementia,  in  idiots,  and  can  therefore 
likewise  only  be  used  with  great  caution  for  the  establishing 
of  dementia  pra^cox.  Much  more  characteristic  are  negativism 
and  mannerisms,  which  scarcely  accompany  any  other  morbid 
process  uniformly  in  a  pronounced  form  throughout  a  long 
period. 

At  this  point  meantime  the  consideration  arises,  that  it  is 
often  uncommonly  difficult  to  decide  whether  we  really  have 
to  do  with  genuine  catatonic  morbid  symptoms  or  not. 
Automatic  obedience  may  be  simulated  by  shyness  ;  impul- 
siveness of  action  by  obscurity  of  motives  in  clouding  of 
consciousness  with  inhibition  of  the  movements  of  emotional 
expression  ;  stereotypy  by  uniformity  of  volitional  actions,  as 
that  may  be  caused  by  the  domination  of  definite,  over- 
powering ideas  or  emotions.  From  genuine  impulsive 
negativism  there  must  be  distinguished  the  surly,  stubborn 
se>f-will  of  the  paralytic  and  of.  the  senile  dement,  the 
playful  reserve  of  the  hysteric,  the  pertly  repellent  conduct 
of  the  manic,  and  from  the  senseless  perversities  in  action 
and  behaviour,  as  they  occur  in  dementia  pra^cox,  the  con- 
ceited affectation  of  the  hysteric,  as  also  the  wantonly  funny 
solemnity  of  the  manic  patient.  Often  it  will  onl)'  be 
possible  to  find  out  these  and  other  similar  differences  after 
considerable  observation  among  changing  conditions,  after 
having  made  all  sorts  of  experiments  on  the  conduct  of  the 
patients  under  influences  of  various  kinds;  sometimes  informa- 
tion is  first  got  from  observations  in  quite  other  domains 
about  the  correct  interpretation  of  the  phenomena. 

Psychopathic  States. — If  we  now  consider  in  order  the 
diagnosis  of  dementia  praicox  from  individual  disea.ses  of 
another  kind,^  the  question  first  comes  before  us,  how  far  it 
may  be  confused  with  states  produced  by  morbid  predisposi- 
tion. That  among  psychopathic  inferior  personalities  a 
group  is  possibly  found  which  we  may  regard  as  undeveloped 
cases  of  dementia  pra,xox,  as  "  latent  schizophrenia  "  accord- 
ing to  Bleuler's  terminology,  was  formerly  mentioned.  Occa- 
sionally there  come  into  notice  certain  shy,  whimsical, 
queer  people,  and  then  perhaps  many  irritable,  unaccountable 
psychopathies  with  a  tendency  to  distrust  and  overweening 

'  ScViotl,  .Monatsschr.  f.  Psychiatric u.  Neurol,  xvii.  Erg.-Heft99;  Wilmanns, 
Centralblalt  f.  Nervenhcilk.  u.  I'sychiatrie  1907,  569;  Bornstein,  Zeftschr.  f.  d. 
ges.  Neurol,  u   Psychiatric  v.  145. 


DIAGNOSIS  259 

self-conceit,  who  may  at  least  with  a  certain  probability  be 
supposed  to  be  suffering  from  dementia  pra-cox.  On  the 
other  hand  we  cannot  well  accept  such  an  interpretation  for 
the  great  mass  of  those  morbid  states  the  foundation  of 
which  is  anxiety  and  want  of  self-confidence.  If  the  conduct 
of  life  exhibits  here  ever  so  many  peculiarities  and  apparent 
incomprehensibilities,  their  origin  can  yet  invariably  be 
traced  back  in  one  or  another  way  to  intelligible  motives. 
Only  a  small  group  of  childishly  weak-minded,  weak-willed 
personalities  without  initiative,  with  hypochondriacal  failure 
of  volition,  seems  to  belong  to  the  frontier  territory  of 
■dementia  simplex. 

Not  at  all  infrequently  a  commencing  dementia  preecox 
is  looked  on  as  simple  nervousness,  hypochondria  or  neuras- 
thenia and  treated  according})',  and  still  more  frequently 
regarded  as  moral  depravity.  The  increasing  failure  in  work 
is  connected  with  exhaustion  and  over-exertion,  perhaps  also 
with  the  influence  of  some  or  other  occurrence.  Here  above 
everything  the  decisive  points  for  the  diagnosis  are  the  signs 
of  psychic  weakness,  the  want  of  judgment,  the  senselessness 
of  the  hypochondriacal  complaints,  the  inaccessibility  towards 
the  reassuring  statements  of  the  physician,  the  emotional 
dulness  and  want  of  interest,  the  lack  of  improvement  on 
relaxation  from  work,  further,  the  more  or  less  distinct 
manifestations  of  automatic  obedience  or  of  negativism. 
Hallucinations  and  sudden  incomprehensible  impulsive 
actions  naturally  are  wholly  in  favour  of  dementia  praicox. 

Numerous  patients,  who  on  account  of  moral  incapacity 
either  become  habitual  criminals,  or  fall  into  prostitution,  or 
who,  being  incapable  of  earning  a  living,  drift  into  a  vagrant 
life,  are  for  many  years  disciplined  and  punished,  if  the  more 
striking  symptoms  of  dementia  precox  are  absent,  till  the 
appearance  of  more  severe  disorders,  states  of  excitement  and 
stupor,  hallucinations  of  hearing,  and  delusions,  makes  clear 
the  morbidity  of  their  state.  Here  also  the  incoherence  of 
thought  and  action  and  the  peculiar  dulness  with  which  the 
patients  let  everything  happen,  may  give  hints  to  the  expert 
for  a  correct  decision.  Of  special  importance  is  the  proof, 
that  in  a  certain  period  of  life  a  change  of  the  whole 
personality,  a  deterioration  and  a  failing,  has  taken  place ; 
still  the  forerunners  of  such  an  "  acquired  folic  morale,"  as  we 
have  seen,  go  back  even  to  childhood.  Many  patients  fall 
into  drinking  habits  and  then  the  extraordinary  rapidity  is 
surprising  with  which  they  break  adrift,  carry  out  the 
most  incomprehensible  actions,  and  become  completely 
demoralized.        At    the    same    time    there    exists    also    in 


26o  DEMENTIA    PR.4£COX 

sober  moments  a  complete  lack  of  understanding  for  the 
consequences  of  what  has  happened  and  dull  indifference 
towarck  them. 

Imbecility  and  Idiocy. — States  of  weakness,  which  are 
produced  by  dementia  pr.xcox,  may  be  regarded  as  imbecility 
or  idioc)',  especially  when  they  have  already  arisen  in  child- 
hood, while  otherwise  the  previous  history  will  as  a  rule 
point  to  the  peculiarity  of  the  malady.  Sometimes  it  is 
possible  from  the  comparison  of  present  performances  with 
earlier  school  reports,  essays,  letters,  to  establish  the  fact  of 
the  mental  falling  off,  and  from  that  to  conclude  that  the 
case  is  probably  one  of  dementia  pr^ecox.  Where  residua 
of  the  disease,  which  has  been  passed  through,  have  been 
left  behind,  hallucinations  of  hearing,  delusions,  mannerisms, 
negativistic  features,  the  decision  will  be  easy.  Simple 
rhythmical  movements  are,  however,  not  of  use  for  diagnosis, 
which  may,  as  a  symptom  of  very  profound  injury  to  the 
volitional  mechanism,  be  produced  by  other  morbid  pro- 
cesses. If  it  is  a  case  of  simple  weak-mindedness  without 
specially  characteristic  disorders,  the  disproportion  between 
knowledge  and  ability  may  often  give  effective  points  for 
decision.  As  by  dementia  pra'cox  what  is  remembered  is 
less  injured  than  the  ability  to  use  it,  we  often  still  find 
surprising  knowledge,  while  efificiency  has  suffered  most 
severe  losses.  Imbeciles  on  the  contrary  can  often  manage 
fairly  well  in  their  daily  tasks,  even  when  their  knowledge 
is  of  the  very  lowest  degree.  Correct  recognition  is  very 
important  especially  in  military  service,  as  the  profound 
incapacity  of  the  hebephrenic  is  easily  interpreted  as  laziness 
and  obstinacy  and  then  leads  to  discipline  which  may  have 
as  a  consequence  serious  exacerbations  of  the  state.  Weak- 
mindedness  which  has  existed  from  childhood  without  focal 
phenomena,  which  later  experience  an  exacerbation,  is  as 
a  rule  to  be  regarded  as  engrafted  hebephrenia,  if  epilepsy 
and  cerebral  syphilis  can  be  excluded,  the  former  by  the 
absence  of  seizures,  the  latter  by  the  negative  result  of  the 
Wassermann  reaction.  In  many  cases  the  recognition  of 
the  condition  is  made  essentially  easier  by  the  failure  of  the 
psychic  pupillary  reaction. 

Manic-depressive  Insanity. — By  far  the  most  important 
point  in  diagnosis,  but  at  the  same  time  also  the  most 
difficult,  is  the  distinguishing  of  dementia  pra^cox  from 
isolated  attacks  of  manic-depressive  insanity.^  As  little  as 
we  can  doubt  that  here  we  have  to  keep  separate  two  morbid 

'  Urstein,  Die  Dementia  pnx'cox  und  ihre  Stellung  zum  maiiisch-depressiven 
Irresein.  1909;  Thomsen,  AUgem.  Zeitschr.  f.  Psychiatric,  Ixiv.  631. 


DIAGNOSIS  261 

processes  quite  different  in  their  character,  and  as  simple 
as  the  delimitation  is  in  the  great  majority  of  cases,  Just  as 
ihsufficient  do  our  distinguishing  characteristics  yet  appear 
in  those  cases  in  which  we  have  before  us  a  mingling  of 
morbid  symptoms  of  both  psychoses. 

Opinions  still  differ  widely  as  to  whether  here  greater 
weight  must  be  attributed  to  the  catatonic  or  to  the  circular 
symptoms  for  the  classification  of  the  case.  I  consider  indeed 
the  putting  of  this  question  wrong,  and  am  coming  more 
and  more  to  the  view  that  one  must  on  principle  beware 
of  attributing  characteristic  significance  to  a  single  morbid 
phenomenon.  Not  even  states  differing  so  widely  from  each 
other  as  manic,  paralytic,  and  alcoholic  excitement  can  be 
distinguished  from  each  other  with  certainty  on  the  ground 
of  a  single  psychic  characteristic.  We  must  indeed  also  keep 
in  mind  that  the  causes  of  disease  everywhere  meet  preformed 
mechanisms  in  our  brain,  whose  independent  morbid  activity 
attains  to  expression  in  the  clinical  picture.  All  possible 
stimuli  will,  therefore,  by  their  attack  at  the  same  point  be 
able  to  call  forth  perhaps  very  similar  psychic  morbid 
phenomena.  But  what  hardly  ever  is  produced  in  quite 
the  same  way  by  morbid  processes  of  different  kinds,  is,  as 
already  mentioned  above,  the  total  clinical  picture,  including 
development,  course  and  issue.  If,  therefore,  isolated  morbid 
symptoms  and  in  certain  circumstances  whole  pictures  of 
states  cannot  always  be  interpreted  with  certainty  in  the 
sense  of  a  definite  disease,  a  complete  survey  of  the  whole 
disease  will  then  at  least  invariably  lead  to  the  goal,  when 
our  knowledge  of  the  domain  concerned  already  suffices  for 
the  needs  of  such  a  task. 

In  the  controversy  about  the  significance  of  isolated 
morbid  symptoms,  however,  it  must  further  be  kept  in  view, 
that  their  value  is  of  very  varied  kind.  Thus  the  frequently 
employed  conception  of  "  catatonic  "  phenomena  ^  embraces  a 
number  of  characteristics  which  are  only  in  the  smallest  part 
specially  peculiar  to  catatonia.  Catalepsy,  echophenomena, 
making  faces,  affected  behaviour,  speaking  past  the  subject, 
speaking  in  artificial  languages,  rhythmic  movements,  peculiar 
gestures  and  attitudes,  none  of  these  by  themselves  alone 
justify,  as  with  VVilmanns  I  must  emphasize,  the  regarding  of 
a  case  as  catatonia.  A  more  or  less  convincing  proof  is 
given  by  their  accumulation  and  their  connection  with  yet 
other  disorders  in  themselves  likewise  not  characteristic,  as 
hallucinations   of  hearing,   delusions    of    influence    on    will, 

1  Soutzo,    Les   symptomes   catatoniques ;     leur    mecanisme    et    leur    valeur 
clinique   1903. 


262  DEMENTIA    PR^XOX 

repellent  conduct,  indifference  towards  the  surroundings, 
lack  of  susceptibility  to  influence,  absence  of  movements  of 
defence,  abrupt  change  from  stupor  to  excitement  and  so  ori. 
As  already  mentioned,  genuine  negativism,  instinctive,  purely 
passive  resistance,  seems  to  me  to  possess  the  relatively 
greatest  significance  as  an  isolated  symptom.  Here  also,  how- 
ever, a  mistake  ma\'  be  made,  especially  as  it  is  sometimes 
impossible  to  be  certain  whether  the  resistance  is  instinctive 
or  founded  on  imagination  and  emotional  occurrences.  The 
same  difficulty  meets  us,  moreover,  in  the  remaining  catatonic 
morbid  symptoms.  On  this  account  they  cannot  always 
signify  the  same  thing,  because  in  the  isolated  case  we  know 
only  the  outward  behaviour  but  not  the  inward  origin. 

As  it  appears  to  me,  the  circular  morbid  symptoms  can 
make  just  as  little  claim  to  inviolable  diagnostic  significance. 
In  the  first  place  that  is  true  for  the  periodic  and  also  for  the 
circular  course,  which,  even  though  perhaps  with  certain 
deviations,  may  occur  in  very  similar  way  in  dementia 
pr.necox.  Manic  pressure  of  activity,  which  in  its  slighter 
forms  is  so  characteristic,  often  in  great  excitement  nearly 
approaches  the  picture  of  catatonic  raving  mania  ;  the  flight 
of  ideas  in  similar  circumstances  becomes  not  infrequently  a 
monotonous,  persistent  drivel.  For  the  inhibition  of  will  and 
thought  the  same  may  be  said  as  for  negativism  ;  it  ma)'  be 
impossible  to  distinguish  them  from  the  failure  of  mental 
activit)-  and  of  volitional  impulse,  which  is  peculiar  to 
dementia  prjecox.  Sometimes  the  patients  are  themselves 
able  to  give  an  account  of  the  inner  origin  of  their  actions, 
which  then  may  become  of  special  importance  .for  the 
interpretation.  Indubitably  even  that  does  not  always  allow 
of  a  certain  judgment  being  made.  At  the  commencement 
of  a  case  of  dementia  precox,  when  the  patients  often  feel 
very  distinctly  the  gradual  annihilation  of  their  will,  one 
hears  from  them  frequently  utterances  quite  similar  to  those 
of  the  manic-depressive  patients,  although  they  are  in  reality 
related  to  essentially  different  processes. 

The  states  of  manic-depressive  insanity  therefore  will  not 
be,  as  I  think,  recognized  from  one  isolated  symptom,  even 
though  it  may  apparently  be  capable  of  only  one  interpreta- 
tion, but  only  from  the  whole  clinical  picture  with  cautious 
weighing  of  the  relations  which  exist  between  the  individual 
features.  P'or  the  delimitation  from  dementia  pra.'cox  great 
weight  must  without  doubt  be  laid  on  "intrapsychic  ataxia," 
which  was  brought  by  Stransky  especially  into  the  fore- 
ground, that  is  on  the  want  of  inner  logical  arrangement  of 
psychic    events,    which     distingui.shes    this    di.sease.       IJn- 


DIAGNOSIS  263 

fortunately  it  is  not  always  easy  to  reco^jnize  the  existence 
of  this  disorder,  as  also  in  the  mixed  states  of  manic-depressive 
insanity  ;  owing  to  injuries  of  various  kinds  to  nearly 
related  functions  and  the  interconnection  of  different  states, 
pictures  may  temporarily  arise  which  externally  at  least  are 
similar.  (Flight  of  ideas  with  inhibition  of  thought,  exalted 
ideas  with  depressive  mood  and  so  on). 

From  different  sides  the  attempt  has  been  made  to  use 
association  experiment  for  the  characterization  of  the  two 
diseases  discussed  here.  Isserlin  draws  .special  attention  to 
the  fact  that  manic-depressive  patients  invariably  exhibit  a 
desire  to  try  the  exercise,  even  though  they  ma\-  appear 
indifferent  and  impoverished  in  thought.  In  contrast  to  that 
there  is  observed  in  dementia  praecox  persistence  of  individual 
answers,  sometimes  through  whole  series  of  attempts,  wholly 
nonsensical  or  manneristic  associations,  repellent  conduct, 
abrupt  change  between  very  short  and  greatly  prolonged 
periods.  Bornstein  also  found  frequent  absence,  repetitions, 
poverty  of  associations  in  dementia  praicox  in  contrast  to  the 
tendency  of  the  manic  patients  to*  produce  all  possible 
associations  and  to  spin  the  thread  further ;  the  clang- 
associations  which  are  frequent  in  the  latter  were  almost 
ehtirely  absent  in  the  former. 

If  we  now  look  at  the  individual  clinical  states  in  the 
depressive  forms,  the  early  appearance  of  numerous  hallucina- 
tions of  hearing  and  of  nonsensical  delusions,  in  particular 
the  idea  of  influence  on  will,  makes  dementia  praecox  pro- 
bable, especially  if  ordinary  sense  remains  preserved.  Hal- 
lucinations of  hearing  are  in  manic-depressive  insanity  much 
rarer  and  have  generally  a  less  definite  stamp,  so  that  the 
patients  usually  reproduce  their  content  not  in  exact  words 
but  only  in  general  expressions  ;  they  very  frequently  refer 
them  to  their  own  thoughts  as  voices  of  conscience,  and  are 
very  much  disturbed  by  them,  especially  as  the  content  is 
invariably  in  the  closest  relation  to  their  depressive  ideas. 
The  train  of  thought  of  the  patients  is  made  difficult,  and 
they  become  painfully  aware  of  this.  Wilmanns  places 
extraordinary  weight  on  this  "  intrapsychic  inhibition,"  the 
"  feeling  of  insufficiency,"  for  the  diagnosis  of  manic-depres- 
sive insanity,  and  considers  it,  just  like  the  hypomanic  mood, 
to  be  more  characteristic  than  the  "  catatonic  "  phenomena  in 
dementia  praecox.  On  the  other  hand  I  have  still  doubts  of 
all  kinds. 

It  is,  however,  correct,  that  the  patients  with  dementia 
praecox,  who  likewise  often  complain  of  incapacity  for 
thought,  usually  describe  not  so  much  the  feeling  of  inward 


264  DEMENTIA    PRyECOX 

inhibition  as  that  of  influence  by  external  forces ;  they 
cannot  think  what  they  will,  and  must  think  what  they  do 
not  will,  what  is  forced  on  them,  while  the  manic-depressive 
patients  cannot  collect  their  thoughts  and  reduce  them  to 
order,  or  in  certain  circumstances,  as  when  they  have  an 
inward  flight  of  ideas,  cannot  retain  them,  but  they  only 
exceptionally  feel  themselves  dominated  by  external  influ- 
ences. Urstein  thinks  that  the  patients  with  dementia  prse- 
cox  only  feel  subjective  inhibition,  while  the  patients  in  the 
circular  states  of  depression  are  inhibited  subjectively  and 
objectively.     I  cannot  agree  with  either  opinion. 

In  general  there  is  found  in  the  manic-depressive  patients 
more  tendency  to,  and  ability  for,  the  obset~)ation  of  self,  to 
painful  dissection  of  their  psychic  state,  in  contrast  to  the 
indifference  with  which  in  dementia  pr.tcox  we  so  often  see 
the  patients  regard  the  most  deep-reaching  disorders  of  their 
psychic  life.  In  the  latter  even  the  most  exciting  delusions 
are  produced  with  remarkably  slight  emotional  participation, 
and  as  a  rule  also  they  do  not  induce  in  the  patient  any 
definite,  intentional  miction.  It  is  striking  in  the  highest 
degree  that  the  patients  are  usually  not  at  all  disturbed  by 
"the  phenomenon,  just  as  mysterious  as  it  is  weird,  of  hearing 
voices,  apart  from  their  content  sometimes  provocative, 
sometimes  wholly  trifling,  and  often  for  months  do  not  utter 
the  slightest  complaint  on  that  account,  when  they  are  not 
specially  questioned  on  the  subject.  Generally  it  is  only 
with  difficulty  that  a  glance  is  gained  into  the  occurrences  of 
their  inner  life,  even  when  the  patients  are  able  to  give 
utterance  without  difficulty  to  their  thoughts ;  they  are 
taciturn,  repellent,  evade  questions,  give  indefinite  information 
that  tells  nothing.  Neither  do  they  take  any  share  in  what 
happens  in  their  surroundings;  they  do  not  greet  their 
relatives  who  visit  them,  they  do  not  speak  a  word  during 
the  visit,  but  perhaps  devour  greedily  everything  that  is 
brought  to  them. 

In  contrast  to  that  the  signs  of  anguish  or  dejection  are 
never  absent  in  circular  states  of  depre.ssion.  It  is  true  that 
the  expression  of  the  inward  states  may  be  limited  to  a  con- 
siderable extent.  Nevertheless  the  emotional  susceptibility 
to  influence  is  shown  by  stimulation  of  ideas  emphasized  by 
emotion,  by  letters,  by  visits,  with  considerable  persuasion 
most  unmistakably  in  the  signs  of  tension  or  excitement, 
sometimes  even  in  violent  outbursts  of  feeling.  By  the 
occurrences  in  their  surroundings  the  patients  are  much 
more  strongly  moved,  relate  them  to  themselves,  fall  into 
anxiety.     While  in  dementia  pracox  the  emotions  are  silent, 


DIAGNOSIS  265 

without  the  patients  noticing  the  disorder,  or  being  disturbed 
about  it,  the  manic-depressive  patients  complain  in  despairing 
accents  of  the  feeling  of  inward  desolation  and  emptiness, 
of  their  inability  to  feel  joy  or  sorrow,  although  in  their 
conduct  emotional  reactions  of  great  vivacity  appear. 
Towards  the  physician  likewise  they  are  indeed  often  mono- 
syllabic, but  do  not  make  evasions  ;  they  let  themselves  be 
stirred  up  by  persuasion  to  further  utterances,  and  they 
invariably  bring  forth  their  complaints  with  the  signs  of 
inward  agitation.  Their  activity  is  developed  logically  from 
their  ideas  and  from  their  mood  even  when  in  itself  it  is 
ever  so  nonsensical,  while  frequently  in  dementia  praecox 
very  sudden  impulses,  not  explicable  even  to  the  patient 
himself,  interrupt  the  inner  connection  of  psychic  events. 

Monotonous  lamentation  of  anxious  patients  must  not  be 
allowed  to  mislead  to  tlie  assumption  of  catatonic  stereotypy. 
The  constant  return  of  the  same  utterances  and  gestures  is 
here  not  the  result  of  senseless,  perseverating  impulses,  but 
the  expression  of  a  permanent  emotional  reaction  dominating 
everything,  which  continually  produces  the  same  ideas  and 
tries  to  express  itself  by  the  same  expedients.  It  is  true 
that  the  originally  intelligent  movements  and  utterances  in 
the  course  of  time  show  a  certain  rigidity,  pulling,  tripping, 
arranging,  rhythmic  screaming.  A  female  patient  for  years 
imitated  the  movements  and  noises  of  the  wild  animals  into 
which  she  thought  she  was  transformed.  As  a  rule  it  will 
be  possible  to  demonstrate  their  origin  from  ideas  and 
emotions  in  contrast  to  the  purely  impulsive  senseless  dis- 
charges of  volition  in  dementia  praecox. 

Very  important  is  the  distinction  of  negativism  from 
the  anxious  resistance  and  the  inhibition  of  will  in  manic- 
depressive  insanity.  Even  the  behaviour  at  the  approach 
and  greeting  of  the  physician  permits  certain  conclusions 
to  be  made.  The  negativistic  patient  does  not  look  up, 
hides  himself  perhaps,  turns  away  or  stares  straight  in  front 
of  him,  and  does  not  betray  by  any  movement  of  a  muscle 
that  he  is  aware  of  anything.  All  the  same  he  usually 
perceives  better  than  the  manic-depressive  patient,  who 
indeed  also  perhaps  remains  mute  and  motionless,  but  still 
in  his  glance,  in  the  expression  of  his  face,  in  slight  attempts 
at  movement,  acceleration  of  the  pulse,  flushing,  stoppage  of 
respiration,  lets  it  be  seen  that  he  has  felt  the  impressions. 
In  the  negativistic  patients  further  we  meet  rigid  resistance 
at  every  attempt  to  change  their  position,  but  only  on  actual 
interference ;  on  the  other  hand  the  patients  endure  simple 
or  even  painful  touches  and  even  dangerous  threats  (needle 


266  DEMENTIA   PRECOX 

at  eye)  for  the  most  part  without  defending  themselves,  do 
not  fall  into  excitement,  at  most  move  out  of  the  way,  let 
the  needle  stuck  into  their  eyelid  remain  sticking.  Lastly 
the  resistance  may  of  itself  or  under  the  influence  of  prudent 
compulsion  pass  directly  into  automatic  obedience.  In  the 
manic-depressive  cases  on  the  other  hand  resistance  begins 
with  the  threatening  danger,  no  matter  whether  a  change 
of  position  takes  place  or  not ;  nor  do  the  limbs  moved  out 
of  their  position  take  up  again  with  inviolable  tenacity 
exactly  the  former  attitude.  At  the  same  time  a  threatening 
approach  leads  to  lively  expressions  of  emotion,  to  screaming, 
evasion,  anxious  defence. 

The  stuporous  catatonic  usually  moves  little  or  not  at  all, 
especially  not,  if  asked  to  do  so.  Persuasion  has  no  result  or 
it  makes  resistance  still  greater.  But  if  he  does  do  anything, 
which  cannot  be  reckoned  on,  this  happens  without  recogniz- 
able retardation,  often  even  with  uncommon  rapidity,  while 
in  the  patient  suffering  from  inhibition,  such  actions,  which 
require  volitional  resolves,  are  carried  out  slowly  and  hesitat- 
ingly, as  can  be  demonstrated  now  and  then  even  in  quite 
simple  movements  or  answers.  Sometimes  in  inhibition  it 
maybe  demonstrated  that  well-practised  speech  utterances,  as 
numbers,  are  run  off  without  hindrance,  while  difficulties  are 
increased  as  soon  as  the  morbid  ideas  are  touched  on,  a  sign 
that  emotional  influences  play  an  authoritative  part.  Many 
a  movement  which  is  asked  for  remains  wholly  undone,  yet  at 
least  preliminary  movements  for  the  desired  action  (slight 
movements  of  the  lips,  twitching  of  the  fingers}  are  frequently 
seen,  especially  if  the  inhibition  is  gradually  overcome  by 
powerful  persuasion.  Contrariwise  in  catatonics  one  may 
observe  how  the  impulse,  at  first  perhaps  appearing,  is  there- 
upon abruptly  interrupted,  made  retrogressive,  perhaps  even 
turned  into  its  opposite. 

For  distinguishing  the  states  of  excitement  of  dementia 
pra^cox  from  vuinic  seiziwes,  it  must  first  be  noticed,  that  the 
faculty  of  perception  and  ordinary  sense  are  usually  more 
.severely  injured  in  mania  than  in  the  former.  While  the 
patients  even  in  the  wildest  catatonic  mania  are  for  the  most 
part  surprisingly  clear  about  their  position  and  surroundings, 
we  shall  always  meet  in  severe  manic  excitement  considerable 
disorder  of  perception,  of  thought  and  of  orientation.  In  the 
agitated  states  of  dementia  pra;cox  attention  is  scarcely 
occupied  with  the  surroundings,  although  these  are  perceived 
quite  well  ;  it  is  not  easih'  diverted.  The  manic  on  the 
contrary  perceives  inaccurately  and"  fugitively,  and  turns  to 
anything  new  which  enters  into  his  circle  of  vision.    Frequently 


DIAGNOSIS  267 

he  speaks  at  once  to  the  physician,  overwhelms  him  with  a 
throng  of  words,  while  the  patient  suffering  from  catatonic 
excitement  does  not  trouble  himself  about  the  physician, 
simply  continues  his  perpetual  movement  and  can  only  by 
special  exertions  be  brought  to  give  a  sensible  answer. 

In  dementia  praecox  again  conversation  is  frequently 
altogether  senseless  and  incoherent  in  spite  of  very  slight 
excitement,  while  even  in  the  most  violent  raving  mania  we 
seldom  quite  lose  an  at  least  approximate  understanding  of 
the  manic  train  of  thought.  In  the  former  there  is  also 
adherence  to  a  few  expressions  going  as  far  as  marked  verbi- 
geration ;  on  the  other  hand  in  the  manic  train  of  thought,  in 
spite  of  the  absence  of  all  connection,  the  progression  from 
one  circle  of  ideas  to  another  can  still  almost  always  be 
recognized.  Speaking  in  a  self-invented  language  occurs 
also  in  manics,  but  only  in  the  form  of  boasting  about  foreign 
languages ;  in  the  same  way  occasional  neologisms  appear  as 
students'  jokes  and  not,  as  in  dementia  pr?ecox,  as  derail- 
ments of  expression  in  speech.  A  tendency  to  clang-associa- 
tions and  rhyming,  as  well  as  flights  of  ideas,  is  peculiar  to 
manic  conversation  ;  on  the  other  hand  senseless  monotonous 
jingling  of  syllables  gives  evidence  for  dementia  praecox. 

Some  of  these  distinguishing  marks  fall  away  in  mania 
with  inhibition  of  thought,  in  which  the  few  and  monotonous 
speech  utterances  as  well  as  the  vacant  merriment  make  a 
complete  impression  of  weak-mindedness,  and  therefore  can 
bring  the  assumption  of  dementia  praicox  very  near.  How- 
ever, it  has  to  do  here  with  poverty  of  thought  and  conse- 
quently little  substance  in  conversation,  and  not  with  unrelated 
incoherence  and  impulsive  stereotypy.  Laughing  is  often 
connected  with  external  causes,  and  in  the  intervals  isolated 
actions,  more  playful  and  merry  than  senseless,  are  inter- 
polated. 

Mood  is  in  mania  for  the  most  part  cheerful,  merry,  or 
irritable,  but  in  dementia  praecox,  silly,  convulsively  unre- 
strained, or  indifferent  ;  Dreyfus  remarks  that  the  hilarity 
of  the  manic  has  something  infectious  in  it,  in  dementia 
praicox  it  has  something  repulsive  ;  it  has  no  relation  to 
the  ideas  of  the  patients.  In  the  utterances  of  the  patients 
with  dementia  pr?ecox  there  often  continually  appears  even 
in  slight  excitement  a  deliberate  obscenity,  such  as  only 
occurs  once  in  a  way  in  manics  in  occasional  outbursts  of 
abuse. 

Further  there  has  specially  to  be  observed  the  aimlessness 
of  the  catatonic  movements  compared  with  the  pressure  of 
occupation  of  the  manic,  who  invariably  seeks  relations  with 


268  DEMENTIA    PRyECOX 

his  surroundings.  In  catatonics  the  movements  are  mono- 
tonous and  are  repeated  innumerable  times  in  the  same  way, 
while  in  manics  being  dependent  on  changing  impressions, 
ideas  and  feelings,  they  usually  always  assume  new  forms. 
Not  infrequently  we  meet  in  the  excitement  of  dementia 
priecox  a  striking  want  of  relation  between  pressure  of  speech 
'  and  pressure  of  movement,  perhaps  on  account  of  the  fact  that 
they  are  here  not  brought  into  connection  with  each  other 
by  higher  psychic  processes.  The  patients  may  be  in  violent 
movement  without  at  the  same  time  saying  a  word,  or  they 
chatter  incessantly  without  moving  from  the  spot  and  even 
without  lively  gestures.  Therefore  here  the  pressure  of 
movement  is  often  limited  to  a  very  small  space,  perhaps  a 
part  of  the  bed  ;  the  manic  on  the  contrary  seeks  everywhere 
for  an  opportunity  to  occupy  himself,  runs  about,  busies 
himself  with  the  other  patients,  follows  the  ph\'sician,  carries 
on  all  sorts  of  mischievous  tricks.  To  these  are  added  the 
constrained  and  spreading  nature  of  the  movements,  the 
mannerisms  and  nonsensical  impulses  in  catatonia  in  con- 
trast to  the  natural,  and  to  the  healthy  individual  much  more 
comprehensible,  conduct  of  the  manic.  In  other  words,  in 
mania  perception,  thought,  orientation,  are  relatively  more 
profoundly  disordered  than  in  the  excitement  of  dementia 
pnecox,  while  in  the  latter  it  is  specially  emotions,  actions, 
and  speech  expression  which  are  injured  in  a  peculiar  way. 

Special  difficulties  in  delimitation,  as  Wilmanns  rightly 
brings  forward,  are  presented  by  the  mixed  states  of  manic- 
depressive  insanity.  The  differentiation  of  mania  which  is 
poor  in  thought  from  catatonic  excitement  has  been  already 
mentioned.  In  manic  stupor  the  peculiarly  cheerful  mood, 
the  lively,  though  concealed,  attention  to  the  surroundings 
with  slight  senselessness,  the  playful,  certainly  often  scanty 
and  empty  remarks,  the  susceptibility  to  influence  by  per- 
suasion and  external  occurrences,  lastly,  the  occasional 
purposeful,  merry  actions  of  the  manic  as  opposed  to  the 
empty  merriment,  the  indifference  and  the  inaccessibility, 
the  incoherent  unrelated  conversation,  as  well  as  the  non- 
sensical, monotonous,  impulsive  discharges  of  volition  in 
dementia  praicox  might  usually  after  considerable  observation 
make  the  differentiation  possible.  For  the  correct  interpreta- 
tion of  the  remaining  mixed  states  suitable  points  of  view 
can  be  gained  from  the  consideration  of  the  individual 
disorders  which  compose  them. 

The  content  of  the  delusions  offers  in  general  few  effective 
points  for  the  differentiation  of  the  two  diseases  here 
discussed.     Delusions  of  sin,  ideas  of  persecution,  hypochon- 


DIAGNOSIS  269 

driacal  ideas  may  in  both  appear  in  very  similar  forms. 
Exalted  ideas  will  mostly  only  be  met  with  in  manic- 
depressive  insanity  when  other  indications  also  of  the  manic 
state  are  recognizable.  The  delusion  of  physical,  specially 
sexual,  influence  points  with  great  probability,  the  idea  of 
influence  on  thought  and  will  almost  certainly,  to  dementia 
praicox.  Thomsen  points  out  that  the  delusions  in  manic- 
depressive  insanity  have  more  connection  with  one  another, 
have  more  inner  unity,  while  in  dementia  praecox  they  are 
more  changing,  more  incoherent.  The  nonsensical  character 
of  the  delusions  must  not  be  immediately  regarded  as  a  sign 
of  mental  weakness,  still  in  manic-depressive  patients  it  is 
usually  connected  either  with  very  lively  emotional  participa- 
tion or  with  dreamlike  confusion.  Where  these  accompany- 
ing phenomena  are  absent  and  exalted  ideas  are  connected 
with  the  delusion  of  influence  on  will  and  perhaps  persistent 
vivid  hallucinations  of  hearing  still  exist,  the  assumption  of 
dementia  praicox  will  be  justified. 

The  recognition  of  dementia  praecox  is  often  made  specially 
difficult  by  its  course  in  isolated  attacks  separated  by 
approximately  free  intervals.  If  the  clinical  picture  of  the 
state  is  not  wholly  unequivocal,  the  question  in  such  cases 
will  always  have  to  be  raised  whether  it  is  not  a  case  of 
manic-depressive  insanity,  specially  if  at  the  same  time  states 
of  depression  also  alternate  with  those  of  excitement. 
Thomsen  has  rightly  called  attention  to  the  fact  that  the 
course  of  a  single  period  of  manic-depressive  insanity  in 
general  is  usually  more  even.  Sudden  and  abrupt  change  of 
the  states,  as  also  shortness  and  irregularity  of  attacks  and 
intervals,  specially  with  more  frequent  recovery,  will  arouse 
rather  the  suspicion  of  dementia  praecox.  But  above  every- 
thing the  conduct  of  the  patients  during  the  periods  of 
improvement  will  have  to  be  considered.  Apparent  complete 
restoration,  clear  insight  into  the  nature  of  the  disease,  return 
of  former  efficiency,  absence  of  all  peculiarities  in  action  and 
behaviour,  will  make  manic-depressive  insanity  probable, 
though  not  absolutely  certain.  On  the  other  hand  the 
persistence  of  those  peculiarities,  which  we  formerly  became 
acquainted  with  in  the  discussion  of  remissions,  allows  the 
conclusion  to  be  made  that  dementia  praecox  is  present, 
conduct  sometimes  quiet  and  constrained  or  inaccessible  and 
repellent,  sometimes  irritable  and  self-willed  or  capricious 
and  peculiar,  emotional  dulness,  loss  of  endeavour  and 
energy.  Wilmanns  has  in  the  meantime  properly  drawn 
attention  to  the  fact  that  shyness  and  embarrassment  at  the 
examination  may  simulate  the  disorders  named,  further  that 


270  DEMENTIA    PR/ECOX 

in  certain  circumstances  it  may  be  a  case  of  vanishing 
morbid  residua,  lastly,  that  also  in  manic-depressive  patients 
not  infrequently  between  the  attacks  all  kinds  of  abnor- 
malities are  demonstrable.  It  is  true  that  they  might  incline 
more  to  the  states  belonging  to  this  disease,  anxiety  or 
depression,  shyness,  restlessness  and  perplexity,  frequently 
also  lack  of  clear  understanding  of  the  disease. 

Here  it  will  not  always  be  easy  to  arrive  at  a  certain 
judgment  from  the  evidence  which  is  often  so  insignificant. 
Zendig  after  some  years  out  of  370  cases  of  dementia  pr.tcox 
searched  out  127,  in  which  the  diagnosis  had  not  appeared 
quite  certain.  He  came  to  the  conclusion  that  of  them  sixty- 
seven  patients,  the  majority  of  whom  were  women,  were  to  be 
regarded  with  greater  or  less  probability  as  manic-depressive, 
because  they  exhibited  no  abnormalities  at  all,  or  at  least 
only  such  as  may  be  expected  within  the  limits  of  the  disease 
named.  The  result  is,  however,  not  final.  My  experiences 
have  shown  me  that  in  cases  with  no  very  clear  clinical 
morbid  picture  the  possibility  of  dementia  pra^cox  may 
nowhere  be  left  out  of  account,  where  after  the  attack  of 
disease  any  changes  at  all  of  the  psychic  personality  have 
made  their  appearance.  Nevertheless  attacks  which  have 
occurred  many  years  previously,  which  have  resulted  in 
approximate  recovery,  but  still  more  repeated  attacks, 
especially  those  of  contrasted  colouring  which  have  brought 
about  no  recognizable  state  of  weakness  will  with  rare 
exceptions  justify  the  diagnosis  of  manic-depressive  insanity. 

Hysteria. — Very  frequently  cases  of  dementia  pra^cox  are 
regarded  as  hysteria '  ;  on  the  one  hand  the  affected,  often 
erotic,  behaviour  of  the  patients,  on  the  other  hand  the 
appearance  of  hysteroid  convulsive  phenomena  commonly 
leads  to  that.  The  drivelling  terminal  states  with  delusions 
are  then  perhaps  termed  hysteric  insanity.  Maggiotto 
reports  that  among  101  patients  with  the  diagnosis  of  hysteria 
forty-seven  turned  out  to  be  cases  of  dementia  pnecox  ;  in  a 
further  series  of  240  supposed  hysterics  there  were  forty-three 
similar  errors  in  diagnosis.  What  distinguishes  hysteria  and 
dementia  pra.'Cox  from  each  other,  is  above  everything  the 
behaviour  of  the  emotions.  In  hysteria  we  find  a  heightened 
susceptibility  of  the  emotional  life;  in  dementia  pra;cox  the 
susceptibility  is  lowered.  In  hysterics,  therefore,  we  observe 
rapid,  violent,  and  often  even  lasting  influence  by  impressions 
emphasized  by  emotion,  while  the  emotional  reactions  in 
dementia  pra^cox  are  mostly  shallow  or  of  short  duration  and 
essentially  independent  of  external  influences.    The  permanent 

'  Reyneau,  Dimence  pr^coce  et  hysteric.    These.  1905. 


DIAGNOSIS  271 

inner  relations  to  the  occurrences  of  the  external  world, 
as  they  are  developed  in  hysterics  by  the  vivid  emotional 
emphasis  of  the  events  of  life,  are  in  dementia  praecox 
extinguished,  or  at  least  very  much  weakened  ;  the  patients 
remain  indifferent  towards  visits,  surprising  communications, 
exciting  experiences,  which  in  hysteria  immediately  find 
response  in  lively  reactions.  Stransky  points  out  that  the 
patients  with  dementia  prascox  even  after  the  most  violent 
excitement  are  at  once  able  to  fall  quietly  into  deep  sleep, 
while  in  hysterics  the  emotional  reactions  continue  working 
for  a  much  longer  time. 

The  resistance  of  the  hysteric  is  not  impulsive  but  it  bears 
sometimes  the  stamp  of  angry  irritability,  sometimes  that  of 
childish  defiance  or  affected  coquetry  ;  it  is  not  limited  to 
passive  resistance,  as  it  mostly  is  in  dementia  praecox,  but 
leads  to  outbursts  of  indignation  and  to  defensive  movements  ; 
it  can  often  be  calmed  by  persuasion,  in  contrast  to  the  rigid 
lack  of  susceptibility  to  influence  of  the  catatonic.  The 
affected  behaviour  of  the  hysteric  arises  from  the  more  or  less 
clearly  felt  need  of  being  conspicuous  and  of  showing  off.  It 
aims  at  working  on  the  surroundings  and  is  therefore 
definitely  influenced  by  them  and  their  behaviour,  while  the 
mannerisms  in  dementia  prascox  arise  without  purpose,  even' 
constrainedly,  and  do  not  exhibit  the  slightest  relation  to  the 
surroundings. 

Disconnected  talk  is  carried  on  by  hysterics  only  in 
dazed  conditions  with  clouded  consciousness  and  disorienta- 
tion ;  on  the  other  hand  the  incoherence  of  dementia  praecox 
offers  such  a  peculiar  picture  just  because  the  patients  for 
the  most  part  are  wholly  clear.  Moreover,  in  hysteric 
utterances  of  that  kind  the  course  of  definite  train.s  of  thought 
may  usually  still  to  a  certain  extent  be  followed,  the  con- 
nection with  occurrences  in  the  surroundings,  experiences 
emphasized  by  emotion,  dreamy  imaginations  ;  while  in 
dementia  praecox  it  is  a  case  of  a  senseless  sequence  of 
incomprehensible  fragments  of  thought  often  with  persistence 
of  isolated  component  parts.  Also  in  the  speaking  past 
a  subject  of  the  hysterics  the  relation  of  the  evasive  reply 
to  the  question  put  and,  therefore,  their  mental  working  can 
usually  still  be  distinctly  recognized,  in  contrast  to  the 
utterances  of  negativistic  patients,  which  as  a  rule  are  wholly 
disconnected. 

Genuine  hallucinations  in  hysterics  come  under  observa- 
tion only  in  dazed  conditions  or  in  half-waking  states  ;  they 
occur  far  more  in  the  realm  of  sight  than  in  that  of  hearing, 
and    are    mostly   of    an   exciting   nature  ;    it   is    a  case   of 


272  DEMENTIA    PR/ECOX 

threatening  or  beneficent  figures  in  significant  garments. 
The  invariable  appearance  of  hallucinations  of  hearing  even 
by  day  excludes  hysteria  according  to  my  experience,  and 
gives  decisive  evidence  for  dementia  pra^cox  ;  the  same  holds 
true  for  the  undiscerning  continuance  in  ideas  of  persecution 
and  exaltation  after  complete  disappearance  of  clouding  of 
consciousness.  This  observation  is  probably  in  close  con- 
nection with  the  circumstance,  that  in  hysteria  no  weakness 
of  judgment  is  developed,  as  usually  meets  us  in  such  a 
striking  way  in  dementia  praecox  in  the  unresisting  giving 
way  to  the  most  nonsensical  ideas  in  spite  of  perfect  clear- 
ness. In  hysteria  whole  regions  of  the  psychic  life  may 
temporarily  be  forced  out  of  connection  with  consciousness  ; 
but  still  they  go  on  working  approximately  as  at  other 
times,  something  like  separated  choirs.  In  dementia  priucox 
that  connection  remains  preserved,  but  the  psychic  faculties 
lose  their  mutual  inner  contact  like  an  orchestra  without  a 
conductor. 

The  seizures  in  dementia  przecox  are  mostly  fainting  fits 
or  epileptiform  in  character,  still  I  have  repeatedly  observed 
seizures  which  wholly  resembled  those  of  hysteria.  It  m.ay 
be  thought  that  here,  as  occurs  in  manic-depressive  insanity, 
in  epilepsy,  in  paralysis,  in  focal  diseases  of  the  brain, 
the  morbid  process  in  certain  circumstances  is  also  able  to 
set  in  action  psychogenic  disorders.  The  stigmata  of  the 
hysterics  will  not  usually  be  found  in  dementia  praecox,  still 
anaesthesia  of  the  cornea,  of  the  tongue,  of  the  skin  of  the 
face,  may  be  simulated  by  indifference  and  inattention,  or 
by  negativistic  suppression  of  the  reactions ;  unilateral 
absence  of  sensation  may  be  regarded  as  pointing  to  hysteria, 
as  also  circumscribed  paralyses  or  contractures.  The 
dyscestkesicF  of  the  hysterics  are  usually  changing  and  sus- 
ceptible to  influence  up  to  a  certain  degree ;  those  of 
dementia  praecox  are  monotonous  and  obstinate,  and  other- 
wise than  in  hysteria  are  easily  elaborated  to  nonsensical 
hypochondriacal  ideas,  or  ideas  of  persecution.  Occasionally 
I  was  able  to  assign  morbid  states,  which  at  first  looked 
quite  like  hysteria,  to  dementia  pra.'cox,  because  the  psychic 
reaction  of  the  pupils  was  extinguished  ;  further  observation 
confirmed  this  interpretation.  Hiibner  has  reported  similar 
experiences. 

Psychogenic  Psychoses. — Special  difficulties  may  arise 
for  the  correct  apprehension  of  the  morbid  states  in 
prisoners.  Besides  dementia  praecox  psychogenic  forms  of 
disease  come  under  observation  here,  which  may  exhibit 
great  external  resemblance  to  it ;  on  the  one  hand  there  are 


DIAGNOSIS  273 

hallucinatory-paranoid  states,  on  the  other  stuporous  states. 
In  the  former  probably  above  everything  the  absence  of 
characteristic  independent  disorders  of  volition  is  to  be 
emphasized.  Mannerisms  and  stereotypies  are  absent,  as 
also  genuine  negativism,  which,  however,  in  consequence  of 
delusions,  may  be  simulated  by  repellent  behaviour.  The 
patients  are  confused  only  in  excitement,  and  when  consci- 
ousness is  clouded,  but  do  not  exhibit  the  incoherence  of 
dementia  pra^cox  which  continues  even  without  emotional 
reaction  and  with  complete  clearness.  As  a  rule  hallucina- 
tions and  delusions  last  comparatively  only  a  short  time  and 
disappear  soon  on  the  removal  of  the  patients  to  suitable 
surroundings,  especially  on  their  being  taken  from  solitary 
confinement.  Even  when  the  delusions  are  not  forgotten  or 
corrected,  there  is  still  no  further  elaboration,  and  also  no 
development  of  weak-mindedness  and  no  decay  of  the  psychic 
personality.  The  patients  remain  natural  in  their  conduct, 
preserve  their  emotional  activity  and  are  able  to  take  up 
their  former  life  again. 

In  states  of  stupor  the  patients  are  inaccessible,  mute  and 
resistive,  like  the  catatonics,  but  it  is  usually  easy  to  persuade 
oneself  soon  that  their  conduct  is  not  impulsive,  but  is  deter- 
mined by  ideas  and  emotional  reactions.  They  provide  in 
an  orderly  way  for  the  satisfaction  of  their  needs,  observe 
their  surroundings,  try  to  occupy  themselves  in  some  way  or 
other,  are  clearly  affected  by  external  influences,  and  an 
increase  of  their  stupor  can  at  once  be  recognized  as  soon  as 
one  occupies  himself  with  them.  In  contrast  to  that,  nega- 
tivistic  stupor  in  its  rigid  constraint  exhibits,  it  may  be, 
sudden  and  quite  incalculable  changes,  but  is  in  the  highest 
degree  independent  of  external  occurrences. 

Dissimulation. — The  silly,  capricious  behaviour,  the  re- 
pellent attitude  and  the  speaking  past  the  subject  of  nega- 
tivistic  patients,  further  the  absence  of  natural  reactions  to 
external  interference,  sometimes  arouse  the  suspicion  of 
deliberate  dissimulation.  In  this  domain  the  utmost  caution 
is  necessary.  In  several  such  cases,  in  which  I  believed  with 
certainty  that  I  had  to  do  with  undoubted  dissimulation,  I 
nevertheless  saw  dementia  praicox  develop  later.  Here 
inquiry  must  be  made  whether  in  the  previous  history 
morbid  features  in  the  sense  of  that  malady  have  not  already 
been  demonstrable,  whether  an  intelligible  motive  for  dis- 
simulation is  present,  whether  the  phenomena  have  imme- 
diately followed  the  arrest  or  the  sentence,  whether  they 
continue  when  the  patient  thinks  he  is  unobserved,  whether 
they  are  susceptible  to  psychic  influences.     If  mannerisms, 

S 


274  DEMENTIA    PRECOX 

stereotypies,  or  hallucinations  of  hearing  appear,  the  assump- 
tion of  dissimulation  is  of  course  unfounded. 

Epilepsy. — As  in  dementia  prascox  epileptiform  seizures 
occur,  the  malady  may  be  taken  for  epilepsy  ;  Nacke  has 
described  cases  as  "late  epilepsy,"  which  obviously  were  in 
substance  dementia  pr^ecox.  For  the  most  part,  however, 
the  seizures  in  dementia  prsecox  onh*  appear  as  isolated 
phenomena,  as  precursors  of  the  disease,  or  after  it  has  existed 
for  many  years.  Rarely  it  comes  once  in  a  while  to  an 
accumulation  like  a  status  in  which  the  patients  may  succumb. 
Once  I  observed  in  a  catatonic  such  frequent  and  regular 
epileptiform  seizures,  but  with  them  also  hysteroid  seizures, 
that  I  was  tempted  to  believe  in  a  more  chance  connection  of 
the  two  diseases  without,  however,  becoming  clear  on  the 
subject.  Morawitz '  has  described  a  series  of  similar  cases 
with  epileptic  seizures  existing  from  childhood,  and  he  inter- 
prets them  as  epilepsy  with  catatonic  features.  The  remain- 
ing phenomena  of  epilep.s}-  are  absent  in  dementia  prascox. 
The  weak-mindedness  caused  by  epilepsy  has  also  essentially 
different  features.  It  is  characterized  by  impoverishment  of 
the  range  of  ideas  up  to  the  most  ordinary  things  of  everyday 
life,  limitation  of  the  emotional  relations  to  the  welfare  and 
the  woes  of  the  patient's  own  person  and  his  nearest  relatives, 
great  weakening  and  imperfections  of  memory  with  preser- 
vation of  orderly  thought,  action  and  behaviour.  If  with 
this  is  compared  the  incoherence  of  thought  with  fairly  good 
preservation  of  memory,  the  general  emotional  dulness,  the 
profound  disorder  of  volitional  action,  as  we  meet  it  in 
dementia  prascox,  the  differentiation  of  the  states  will  not 
generally  be  difficult. 

On  the  other  hand  it  has  repeatedly  happened  to  me  that 
I  have  taken  commencing  catatonias  for  the  dazed  condition 
of  epilepsy.  To  take  the  one  for  the  other  is  especially  easy, 
if  perhaps  a  convulsive  seizure  has  preceded.  A  point  for 
differentiation  may  be  given  by  the  negativism  of  the  catatonic 
as  opposed  to  the  anxious  resistance  of  the  epileptic.  Percep- 
tion andorientation  might  for  the  most  part  be  more  profoundly 
disordered  in  the  dazed  state  of  epilep.sy  than  in  catatonia. 
Senseless  answers  to  simple  questions,  rapid  and  correct  per- 
formance of  commands  point  more  to  catatonia.  In  epilepsy 
the  anxious  or  ecstatic  mood  usually  lets  it.self  be  clearly 
seen  ;  action  is  generally  not  so  much  impulsive  as  dominated 
by  definite  delusional  ideas  and  feelings,  which  also  come  to 
light  in  conversation.  Therefore  we  more  frequently  see 
the  epileptic  making  assaults  or  attempts  at  flight  or  com- 
^  Morawitz,  Klinische  Mischformen  von  Epilepsie  und  Katatonie.  Diss.  1900. 


DIAGNOSIS  275 

mitting  deeds  of  violence,  while  the  activity  of  the  catatonic 
bears  the  characteristics  of  the  senseless  and  peculiar,  and 
betrays  fewer  relations  to  the  surroundings.  A  certain 
stereotypy  of  speech  and  action  may  occur  in  both  states,  as 
also  loss  or  clouding  of  memory.  On  the  other  hand  the 
previous  history  generally,  the  further  course  always,  will 
soon  make  the  condition  of  things  clear. 

Paralysis. — The  delimitation  of  dementia  prsecox  from 
paralysis  has  lost  almost  all  its  former  difficulties  by  cyto- 
logical  and  especially  serological  investigation.  In  the  con- 
junction with  lues,  which  occasionally  occurs,  we  find,  indeed, 
deviation  of  complement  in  the  blood  and  perhaps  increase  of 
cells  in  the  cerebro-spinal  fluid,  but  never  the  VVassermann 
reaction  in  the  latter  which  is  so  characteristic  of  paralysis. 
If  further  the  physical  symptoms  of  paralysis  are  taken  into 
account,  especially  the  reflex  rigidity  of  the  pupils,  the  dis- 
orders of  speech  and  writing,  the  seizures  accompanying  focal 
phenomena,  the  distinction  will  usually  be  easy,  particularly 
as  the  age  of  the  patients  also  gives  some  evidence  for  the 
decision.  The  most  important  characteristics  for  the  differ- 
entiation, which  result  from  psychic  findings,  have  already 
been  mentioned  in  the  section  about  paralysis. 

Amentia.^ — The  states  in  dementia  prsecox  which  are 
accompanied  by  confused  excitement  and  numerous  hallucina- 
tions, have  often  been  called  amentia  and  traced  back  to 
exhausting  causes.  Experience  has  shown  me  that  cases  of 
that  kind  cannot  be  separated  from  the  remaining  forms  of 
dementia  prascox  according  to  the  origin,  course  and  issue. 
Only  among  the  psychoses  developing  in  immediate  sequence 
to  severe  infectious  diseases  is  there  a  group  of  cases  to  be 
differentiated,  which  in  their  clinical  picture,  as  in  their 
further  development,  deviate  from  dementia  precox,  and  are 
caused  by  the  toxins  of  infectious  diseases.  The  points  of 
view,  which  for  their  characterization  as  opposed  to  the 
disease  here  treated  of  come  into  consideration,  have  been 
discussed  in  the  individual  forms  of  infectious  insanity. 
Laures-  calls  them  by  the  name  "  demence  precoce  acci- 
dentelle  "  in  contrast  to  the  real  "  demence  precoce  constitu- 
tionelle  "  ;  this  in  my  opinion  is  not  expedient  and  leads  to 
error. 

Cerebral  Syphilis. — Considerable  difficulties,  which  at 
present  cannot  always  with  certainty  be  overcome,  may  arise, 
when  there  is  a  question  whether  certain  acute  hallucinatory 
states  of  excitement  in  patients  demonstrably  syphilitic  ar^ 

^  Confusional  or  delirious  insanity. 

-  Luures,   La  confusion  mentale  chronique  et  ses  rapports  avec  la  demence 
precoce,  1907. 


276  DEMENTIA    PR.^iCOX 

to  be  regarded  as  the  expression  of  syphilis  or  of  dementia 
praecox  by  chance  accompanied  by  syphilis.  A  series  of 
such  cases  have  occurred  in  my  experience ;  in  all  of  course 
paralysis  could  be  excluded  according  to  the  points  of  view 
expounded  above.  Here  the  demonstration  of  bodily 
symptoms  seems  to  me  to  be  of  importance,  which  may  point 
to  the  existence  of  a  cerebro-spinal  syphilis  (lymphocytosis 
of  the  cerebro-spinal  fluid,  disorders  of  the  pupillary  play,  of 
reflexes,  paralyses  of  the  ocular  muscles,  disorders  of  speech 
and  writing,  pareses,  seizures),  on  the  other  hand  the  absence 
of  independent  disorders  of  volition  (negativism,  mannerisms, 
also  stereotypies),  further  of  torpor,  and  the  preservation  of 
emotional  activity.  All  these  symptoms  would  give  more 
evidence  for  a  syphilitic  foundation  for  the  morbid  state,  as 
also  conspicuous  improvement  of  the  same  under  specific 
treatment.  In  the  rare  cases  in  which  once  in  a  while  in  a 
case  of  focal  disease  of  the  brain  "  catatonic  "  symptoms  are 
observed,  the  demonstration  of  the  focal  phenomena  should 
keep  us  from  the  assumption  of  dementia  prsecox. 

Paranoid  Diseases. — At  present  the  delimitation  of 
dementia  praecox  from  certain  paranoid  diseases  appears 
least  of  all  to  be  cleared  up.  Genuine  paranoia  itself  is 
certainly  not  easily  mistaken  for  it.  In  paranoia  above 
everything  the  independent  disorders  of  volition  are  absent. 
While  our  paranoid  patients  because  of  the  regardless 
folly  and  danger  of  their-  activity  usually  very  soon  come 
into  conflict  with  their  neighbours  and  with  the  public 
authorities,  true  paranoiacs  usually  control  themselves  so  far, 
that  more  serious  collisions  with  other  individuals,  as  with 
public  authorities,  are  avoided  ;  they  preserve  also  in  the 
essentials  the  capacity  of  managing  to  a  certain  e.xtent  in 
the  struggle  of  life.  Their  actions  and  behaviour  appear 
only  in  so  far  abnormal  as  they  are  the  outcome  of  their 
delusions  ;  for  the  rest  they  are  mostly  commonplace  and  in- 
conspicuous. Negativism,  mannerisms,  stereotypy,  confusion 
of  speech,  neologisms  are  completely  absent,  as  also  the 
phenomena  of  influence  on  will.  To  that  has  to  be  added 
that  the  patients  do  not  suffer  from  hallucinations,  that 
their  delusions  are  not  incoherent  and  nonsensical,  but 
connected  and  mentally  elaborated,  that  the  emotional 
reactions  have  suffered  no  loss. 

In  the  further  course  also  it  is  seen  that  destruction  and 
finally  disintegration  of  the  personality  does  not  take  place 
as  in  dementia  praecox,  that  much  rather  the  inner  unity  of 
the  psychic  processes  remains  permanently  preserved.  If 
we  see  the  patients  after  five  or  six  years  again,  the\-  appear 


DIAGNOSIS  277 

in  essentials  unchanged,  perhaps  a  little  more  resigned  and 
by  all  kinds  of  experiences  of  life  made  more  mellow,  but 
with  the  old  ideas,  perfectly  reasonable  and  well-balanced 
in  conversation,  bearing,  and  behaviour.  The  paranoid 
patients  in  dementia  praicox  in  favourable  cases  repudiate 
their  former  delusions,  yet  have  become  shy,  quiet,  indifferent, 
weak  of  will.  Or  they  bring  forward  other  similar  ideas  but 
in  a  more  disconnected,  more  extraordinary  form,  without 
proportionate  emotional  emphasis,  contradictory,  without 
mental  elaboration,  without  essential  influence  on  endeavour 
and  action.  But  just  as  frequently  they  present  the  picture 
of  one  of  the  terminal  states  described  with  its  many 
fluctuations,  and  are  incoherent,  silly,  manneristic,  negativistic 
or  dull. 

The  differentiation  of  paranoid  dementia  praicox  from 
the  similar  alcoholic  and  syphilitic  morbid  states  we  have 
already  tried  to  make  clear  in  another  place.  The  reasons 
why  we  have  thought  that  we  should  give  some  other  forms 
of  paranoid  diseases  an  independent  position,  we  shall 
explain  in  the  next  section.  Unfortunately  there  we  shall 
frequently  have  to  move  on  very  uncertain  ground. 


CHAPTER   XII. 
HOW  TO  COMBAT   IT. 

As  we  do  not  know  the  actual  causes  of  dementia  prrecox, 
we  shall  not  be  able  at  present  to  consider  how  to  combat 
it.  Lomer  has,  it  is  true,  proposed  as  a  heroic  prophylactic 
measure  bilateral  castration  as  early  as  possible,  but  scarcely 
anyone  will  be  found  who  would  have  the  courage  to  follow 
him.  Besides  Henneberg  in  a  case  of  pseudo-hermaphroditism 
saw  just  after  the  removal  of  the  testes,  which  were  situated 
in  the  inguinal  region,  a  paranoid  psychosis  develop,  which 
probably  belonged  to  the  domain  of  dementia  pra-cox.  One 
of  my  patients,  a  physician,  who  castrated  himself,  experienced 
no  improvement  of  his  condition  by  it. 

Bruce  in  connection  with  his  discovery  of  a  streptococcus 
tried  without  success  the  iimnunization  of  a  patient  by 
sensitized  goat's  serum  ;  in  another  case  beginning  acutely 
he  used  dead  bouillon  cultures  with  favourable  effect  accord- 
ing to  his  report.  In  the  meantime  we  shall  regard  this 
attempt  also  with  expectancy.  The  same  may  be  said  of 
the  partial  excision  of  the  thyroid  gland,  which  was  carried 
out  by  Berkley  in  ten  cases  and  is  said  to  have  resulted  in 
six  in  improvement  or  recovery.  He  thought  that  by  re- 
section of  a  lobe  of  the  thyroid  gland  he  would  increase  the 
blood-supply  to  the  parathyroid  glands,  and  he  recommends 
the  administration  of  lecithin  at  the  same  time.  This  pro- 
cedure has  been  several  times  repeated,  by  Judin  in  two 
cases,  by  Kanavel  and  Pollock  in  twelve  cases,  by  van  der 
Scheer  in  seven  cases,  almost  always  without  result  ;  only 
van  der  Scheer  saw  improvement  in  two  cases  of  which  the 
one  ran  its  course  with  Basedow's  phenomena,  the  other 
exhibited  struma.  Pinheiro  and  Riedel  report  somewhat 
more  favourable  results.  Pighini  saw  on  administration  of 
parathyroidin  improvement  of  the  pulse  and  of  the  disorders 
of  metabolism  which  were  found  by  him.  Many  years  ago 
I  endeavoured  for  a  long  time  to  acquire  influence  on 
dementia  pra-cox  by  the  introduction  of  preparations  of 
every  possible  organ,  of  the  thyroid  gland,  of  the  testes,  of 
the  ovaries  and  so  on,  unfortunately  without  any  effect. 


HOW   TO   COMBAT   IT  279 

Prophylaxis. — In  children  with  such  characteristics  as  we 
so  very  frequently  find  in  the  previous  history  of  dementia 
prascox,  one  might  think  of  an  attempt  at  prophylaxis, 
especially  if  the  malady  had  been  already  observed  in  the 
parents  or  brothers  and  sisters.  Whether  it  is  possible  in 
such  circumstances  to  ward  off  the  outbreak  of  the  threaten- 
ing disease,  we  do  not  know.  But  in  any  case  it  will  be 
advisable  to  promote  to  the  utmost  of  one's  power  general 
bodily  development  and  to  avoid  one-sided  training  in  brain- 
work,  as  it  may  well  be  assumed  that  a  vigorous  body  grown 
up  under  natural  conditions  will  be  in  a  better  position  to 
overcome  the  danger  than  a  child  exposed  to  the  influences 
•  of  effeminacy,  of  poverty,  and  of  exact  routine,  and  especially 
of  city  education.  Childhood  spent  in  the  country  with  , 
plenty  of  open  air,  bodily  exercise,  education  beginning  late 
without  ambitious  aims,  simple  food,  would  be  the  principal 
points  to  keep  in  view.  Meyer,  who  regards  dementia 
prascox  essentially  as  the  effect  of  unfavourable  influences 
of  life  and  education  on  personalities  with  abnormal  dis- 
positions, hopes  by  all  these  measures  to  be  able  to  prevent 
the  development  of  the  malady. 

Treatment  of  Symptoms. — With  regard  to  the  main 
point  we  see  ourselves  for  the  present  thrown  back  solely 
on  treating  the  phenomena  of  the  disease  already  present. 
Firstly  in  the  cases  which  arise  acutely  or  subacutely  the 
placing  of  the  patient  in  an  institution  is  necessary  to  prevent 
accidents  and  suicide.  Rest  in  bed,  supervision,  care  for 
sleep  and  food,  are  here  the  most  important  requisites.  In 
the  states  of  excitement  prolonged  baths  are  suitable,  the 
employment  of  which,  it  must  be  admitted,  often  meets  with 
great  difficulties,  as  the  patients  do  not  remain  in  the  bath, 
but  always  jump  out  again,  perform  neck-breaking  gym- 
nastics, roll  about  on  the  floor.  The  next  thing  now  to  be 
tried  is  to  quiet  the  patient  so  far  by  a  sedative,  hyoscine, 
sulphonal,  trional,  veronal,  that  he  may  remain  some  hours 
in  the  bath  ;  he  then  usually  soon  becomes  accustomed  to  it, 
and  now,  while  whirling,  splashing,  plunging,  turning  round, 
gesticulating,  only  makes  passing  attempts  to  leave  the  warm 
water  and  lets  himself  be  brought  back  again  to  it  without 
difficulty. 

If  in  very  severe  and  lasting  excitement  this  procedure  is 
unsuccessful,  the  best  expedient,  which  invariably  after  a 
longer  or  shorter  time  leads  to  the  goal,  is  the  employment  of 
moist  warm  packs.  After  a  preliminary  resistance  of  short 
duration  the  patient  usually  with  surprising  rapidity  consents 
to  these  measures,  even  if,  as  with  us,  the  coverings  are  on 


28o  DEMENTIA   PRyECOX 

principle  not  fastened.  If  he  unrolls  himself,  as  happens 
fairly  soon  at  first,  the  attempt  is  again  made  to  keep  him  in 
the  bath,  and,  if  the  restlessness  makes  that  impossible,  the 
pack  is  renewed.  This  procedure  in  severe  cases,  helped  in  the 
beginning  by  sedatives,  is  continued  day  and  night  without 
interruption,  but  so  that  after  at  longest  two  hours  the  pack 
is  exchanged  for  the  bath,  and  the  patient  after  one  or  two 
hours  only  then  returns  to  the  pack,  if  he  will  by  no  means 
remain  in  the  bath.  By  such  a  regulated  continuous  change 
between  pack  and  bath  the  most  severe  states  of  excitement 
are  usually  so  far  moderated  after  a  few  days  that  the  simple 
bath  treatment,  or  even,  if  at  first  only  temporarily,  rest  in 
bed  is  possible.  Care  for  regular  feeding  in  very  reduced, 
sleepless,  resistive  patients,  in  certain  circumstances  by  the 
stomach-tube,  is  requisite,  as  also  the  regulation  of  the  bowels, 
and  the  cleansing  of  the  mouth,  which  is  often  encrusted  by 
the  continuous  screaming  and  speaking. 

During  states  of  stupor  the  continual  refusal  of  food 
may  make  tube-feeding  necessary  ;  frequent  weighing  is  here 
indispensable.  Likewise  the  regular  evacuation  of  the  bowels 
has  to  be  kept  in  mind,  and  because  of  the  negativistic 
retention  of  urine,  which  sometimes  occurs,  of  the  bladder  as 
well.  The  uncleanliness  of  the  patients,  which  is  often  great, 
demands  the  most  careful  attention.  The  danger  of  inten- 
tional and  unintentional  self-inflicted  injuries  can  be  met  to  a 
certain  extent  by  the  use  of  a  padded  bedstead  ;  but  in  spite 
of  that  it  often  enough  still  happens  that  there  are  skin- 
abrasions,  bruises,  furuncles,  and  .so  on,  which  then  show  the 
usefulness  of  the  employment  of  the  prolonged  bath,  and  in 
certain  circumstances  demand  surgical  treatmer.t. 

As  soon  as  the  acute  disorders  disappear,  the  main  thing 
is  to  preserve  as  far  as  possible  what  the  disease  has  not 
destroyed.  Often  the  return  to  the  family  is  now  possible 
and  even  suitable,  if  the  circumstances  are  to  some  extent 
favourable,  and  if  states  of  excitement,  uncleanliness,  refusal 
of  food,  and  similar  more  severe  phenomena  have  not 
remained  behind.  Bleuler  without  hesitation  advises  early 
discharge,  as  he,  in  part  probably  because  of  his  views  of  the 
unfavourable  action  of  certain  complexes,  fears  that  the 
patient  might  "shut  himself  up."  It  is  indeed  the  case  that 
the  removal  to  another  ward  or  institution,  or  to  former 
circumstances,  sometimes  exercises  a  surprisingly  favourable 
influence.  The  patients  who  up  till  then  had  been  perhaps 
wholly  mute  and  inaccessible  begin  already  on  the  journey 
home  to  converse  with  strangers  in  the  train,  .stop  refusing 
food,  go  without  making  any  fuss  to  their  accustomed  work  at 


HOW   TO   COMBAT   IT  281 

home.  Further  it  must  be  acknowledged  that  the  monotonous 
daily  routine  of  institutional  life,  which  relieves  the  patient  of 
all  independent  activity  and  of  all  thought  for  himself, 
secures  to  him,  it  is  true,  far-reaching  protection,  but  at  the 
same  time  must  also  have  an  enervating  influence  and  above 
everything  must  to  a  high  degree  blunt  intellect,  emotion  and 
volition.  To  these  considerations  there  is  certainly  opposed 
the  difficulty  that  many  patients  are  dangerous  to  themselves 
or  to  their  surroundings,  or  are  quite  helpless  and  in  need  of 
careful  attention.  Nevertheless  many  of  the  more  difficult 
patients  behave  themselves  at  home  surprisingly  well,  so  that 
one  does  not  need  to  be  too  anxious  about  experiments  in 
discharge.  In  the  case  of  female  patients,  however,  the 
danger  of  pregnancy,  if  there  is  not  careful  oversight,  is  to  be 
guarded  against.  Where  it  is  possible,  before  the  discharge 
to  the  patient's  own  home,  care  in  a  family  under  medical 
supervision  will  first  be  tried. 

Occupation. — With  all  our  measures  we  can  meantime 
not  prevent  the  great  majority  of  those  who  are  psychically 
crippled  or  half-crippled  after  dementia  prsecox  gradually 
being  gathered  into  large  institutions  and  homes  for  the 
insane,  and  these  patients,  as  they  do  not  quickly  die  off, 
and  often  pass  their  v/hole  life  in  the  institution,  form  the 
great  mass  of  the  insane  who  require  to  be  cared  for.  What 
is  necessary  for  them  is  occupation,  which  alone  can  preserve 
by  exercise  the  capabilities  which  still  remain  to  them,  and 
prevent  them  from  wholly  sinking  into  dulness.  For  them, 
therefore,  perhaps  still  more  than  for  other  forms  of  disease, 
colonies  for  the  insane^  with  their  manifold  opportunities  for 
work  and  treatment  on  general  lines,  preserving  independence 
as  much  as  possible,  are  a  blessing  which  can  scarcely  be  too 
highly  valued  ;  family  care  also  plays  for  them  an  important 
part  as  a  transition  to  discharge  or  as  a  permanent  shelter, 
Frequentl}-  one  sees  even  very  demented  patients  still 
cheerfully  and  usefully  employing  the  remains  of  their 
capabilities  which  the  disease  has  left  to  them,  in  a  circum- 
scribed domain,  in  field  and  garden,  in  cowstall  or  workshop, 
in  sawing  wood  and  cutting  fodder,  in  copying,  drawing, 
reading,  in  cooking,  washing,  or  in  the  ironing-room,  in 
housework,  or  in  the  sewing-room.  In  the  states  of  excite- 
ment, which  occur  very  frequently,  it  usually  suffices  to 
remove  them,  temporarily,  to  supervision  and  rest  in  bed. 

Leucocytosis. — Not  altogether  infrequently  one  sees  the 
psychic  condition  of  the  patients  essentially  improve  under 
the  influence  of  a  fever,  even  in  terminal  states  which  have 
already   lasted  a  long  time  without  change.     Irritable  and 


282  DEMENTIA    PR.-ECOX 

repellent  patients  give  intelligent  information  and  become 
more  accessible ;  negativistic  patients  appear  more  docile 
and  obey  medical  orders  ;  in  paranoid  patients  the  delusions 
pass  into  the  background  ;  dull  patients  apparently  wholly 
demented  show  a  surprising  appreciation  of  the  occurrences 
in  their  surroundings  and  bring  all  kinds  of  old  memories 
to  light.  Unfortunately,  with  the  disappearance  of  the 
bodily  morbid  state,  this  improvement  usually  very  soon 
gives  place  again  to  the  former  behaviour.  It  is  meantime 
a  sign  that  even  very  profound  dementia  is  not  absolutely 
the  expression  of  unalterable  destruction,  but  up  to  a  certain 
degree  is  still  capable  of  amelioration.  It  might  be  thought 
in  a  similar  way,  as  has  been  tried  in  paralysis,  here  also  to 
imitate  the  natural  process  described,  yet  the  few  attempts 
in  that  direction  hav^e  as  yet  not  yielded  any  very  encourag-- 
ing  result.  Thus  Itten  from  this  point  of  view  has  tried  in 
nine  patients  injections  of  sodium  nucleinate.  Nothing  was 
obtained  ;  the  same  is  true  of  some  similar  attempts,  which 
I  made  myself. 


CHAPTER   XIII. 
PARAPHRENIA.! 

The  disintegration  of  the  psychic  personality  is  in  general 
accomplished  in  dementia  pra^cox  in  such  a  way  that  in  the 
first  place  the  disorders  of  emotions  and  of  volition  dominate 
the  morbid  state.  In  contrast  to  that  we  have  now  to  take 
into  consideration  a  comparatively  small  group  of  cases  in 
which,  in  spite  of  many  and  various  points  in  common  with 
the  phenomena  of  dementia  praecox,  but  because  of  the  far 
slighter  development  of  the  disorders  of  emotion  and  volition, 
the  inner  harmony  of  the  psychic  life  is  considerably  less 
involved,  or  in  which  at  least  the  loss  of  inner  unity  is 
essentially  limited  to  certain  intellectual  faculties.  The 
marked  delusions,  the  paranoid  colouring  of  the  morbid 
picture  is  common  to  all  these  clinical  forms  which  cannot 
everywhere  be  sharply  separated.  At  the  same  time  there 
are  also  abnormalities  in  the  disposition,  but  till  the  latest 
periods  of  the  malady  not  that  dulness  and  indifference 
which  so  frequently  form  the  first  symptoms  of  dementia 
praecox.  Lastly,  activity  also  frequently  appears  morbidly 
influenced,  but  essentially  only  by  the  abnormal  trains  of 
thought  and  moods ;  independent  disorders  of  volition  not 
connected  with  these,  such  as  usually  accompany  dementia 
prrscox  in  such  multifarious  forms,  only  come  under  observa- 
tion by  indication  once  in  a  while. 

The  grouping  of  these  paranoid  attacks,  as  well  as  their 
delimitation  from  other  similar  states,  presents  the  greatest 
possible  difficulties.  We  know  indeed  that  isolated  morbid 
phenomena  themselves  only  furnish  us  with  very  unreliable 
means  of  delimiting  forms  of  disease.  It  can  here,  therefore, 
only  be  a  case  of  a  first  tentative  attempt  to  break  up  the 
various  paranoid  morbid  types  into  groups.  If  a  consider- 
able number  of  cases  which  are  accompanied  by  permanent 
delusions  are  examined  carefully,  and  if  the  alcoholic  and 
syphilitic  forms  are  excluded,  it  will  always  be  found  that  a 
very  considerable  part  of  these,  according  to  my  experience 
about  40  per  cent.,  within  a  few  years  exhibit  the  character- 
istics of  dementia  praecox.     A  further  somewhat  larger  part 

^  See  Introduction,  p.   i. 


284  DEMENTIA   PR/ECOX 

falls  to  the  paraphrenic  forms  which  are  to  be  described  here, 
the  rest  essential  1\-  to  real  paranoia. 

Among  the  paraphrenias  again  about  half  exhjbit  that 
slow  but  continuously  developing  mixture  of  delusions  of 
persecution  and  of  exaltation,  as  Magnati  has  described 
them  under  the  name  of  "delire  chronique  a  evolution 
systematique."  ^  Certainly  this  Magnan's  disease,  as  far  as 
can  be  judged  from  the  descriptions  given,  is  according  to 
the  views  brought  forward  here  probabh'  not  a  clinical 
entity ;  we  should  thus  reckon  many  cases  with  marked 
mannerisms  and  numerous  neologisms  which  rapidly  end  in 
weak-mindedness  to  the  paranoid  forms  of  dementia  prrecox 
without  hesitation.  But  at  the  same  time  "  delire  chronique  " 
in  its  developmental  forms  with  their  slow  course  stretching 
over  decades,  einbraces  a  series  of  cases  which  form  the 
nucleus  of  the  first  paraphrenic  morbid  group  to  be  discussed 
here.  As  the  French  word  "delire'"  has  a  different  meaning 
from  our  term  "delirium,"  and  as  also  the  name  proposed  by 
Mobius  for  the  morbid  state,  "paranoia  completa"  no 
longer  corresponds  with  our  views  of  to-day.  I  prefer  to 
speak,  supporting  myself  on  Magnan,  of  a  "paraphrenia 
systematica."  Associated  with  it  then  there  are  as  smaller 
groups,  perhaps  nearly  related  to  each  other,  the  expansive 
and  the  confabulating  form  of  paraphrenia ;  the  last  form, 
the  fantastic,  appears  to  hold  an  exceptional  position. 

Pakai'hrenia   Systematica. 

Paraphrenia  systematica  is  characterized  by  the  extremely 
insidious  de^'elopmetit  of  a  continuously  proi^irssive  delusion  of 
persecution,  to  which  are  added  later  ideas  of  exaltation  icithout 
decay  of  the  personality.  The  beginning  of  the  disease  often 
consists  of  a  change  very  slowly  accomplished  in  the  conduct 
of  the  patient.  He  becomes  gradually  quiet,  sh\',  sometimes 
more  dreamy  and  absorbed,  sometimes  more  distrustful  and 
gloomy,  withdraws  himself  occasionally  carries  on  peculiar 
and  incomprehensible  conversations,  is  conspicuous  in  his 
behaviour,  incalculable,  capricious  in  his  actions.  From  time 
to  time  there  appears  great  sensitiveness  and  irritability  ; 
the  patient  becomes  on  quite  insignificant  occasions  im- 
moderately violent  and  malevolent,  exhibits  embittered  hate 
and  antipathy  towards  individuals  in  his  surroundings,  often 
towards  his  nearest  relatives.  Ideas  of  jealousy  are  specially 
frequent. 

In  course  of  years  a  delusion  of  persecution  becomes  always 

'  Magnan,  Psychiatrische  Vorlesungen,  deutsch  von  Mobius;  Heft  i,  1891. 


PARAPHRENIA  285 

more  and  more  clear.  The  patient  notices  that  he  is  the 
object  of  general  attention.  On  his  appearance  the  neigh- 
bours put  their  heads  together,  turn  round  to  look  at  him, 
watch  him.  On  the  street  he  is  stared  at  ;  strange  people 
follow  him,  look  at  one  another,  make  signs  to  one  another  ; 
policemen  are  standing  about  everywhere.  In  the  restaurants 
to  which  he  goes,  his  coming  is  already  announced  ;  in  the 
newspapers  there  are  allusions  to  him  ;  the  sermon  is  aimed 
at  him  ;  there  must  be  something  behind  it  all.  A  patient 
thought  that  he  must  be  watched  from  the  church  tower. 

The  sentiments  of  the  people  round  him  appear  at  the 
same  time  to  be  anything  but  friendly.  The  inmates  of 
the  house  look  sarcastically  at  him  ;  they  whisper  and  make 
mysterious  sounds  ;  they  separate  from  each  other  as  soon 
as  he  comes.  At  the  habitues'  table  in  the  restaurant  he 
is  jeered  at ;  queer  things  are  said  ;  his  companions  are 
unkind  ;  they  look  askance  at  him,  avoid  him,  greet  him 
without  ceremony,  withdraw  themselves  from  him.  "  It  is 
noticed  when  anyone  has  fine  feelings,"  said  a  patient.  As 
soon  as  he  enters  a  restaurant  people  begin  to  break  up 
the  party.  People  spit  in  front  of  him,  clear  their  throats, 
cough  slightly,  sneeze  in  a  conspicuous  way,  shuffle  with 
their  feet,  ape  his  coughing,  rush  up  against  him.  Detectives 
crowd  round  him  ;  he  has  the  impression  that  he  is  under 
police  supervision.  Always  and  everywhere  there  are  pin- 
pricks, everywhere  chicanery  and  hostility.  "  It's  never 
ending  what  goes  on  there,"  said  a  patient,  "  everywhere  I 
see  allusions,  hints,  a  thousand  things,  which  cannot  be 
described,  which  must  have  been  experienced  in  order  to 
be  understood."  He  also  regarded  a  broken  lamp-glass,  the 
conferring  of  the  military  medal,  as  an  intentional  insult. 
Another  patient  made  the  observation  that  the  number  seven 
pursued  him  everywhere,  and  that  his  fellow-travellers  in  the 
train  invariably  were  grouped  in  the  figure  of  the  Great  Bear. 

Gradually  the  persecution  becomes  always  more  tangible. 
The  patient  cannot  find  rest  any  more  ;  tricks  are  played  on 
him  everywhere ;  everything  is  done  to  spite  him  :  people 
work  systematically  against  him.  The  servants  are  incited 
against  him,  cannot  endure  him  any  longer ;  the  children 
have  no  longer  any  respect  for  him  ;  people  are  trying  to 
remove  him  from  his  situation,  to  prevent  him  from  marrying, 
to  undermine  his  existence,  to  drive  him  into  the  night  of 
insanity.  Female  patients  perceive  that  people  are  trying  to 
dishonour  them,  to  seduce  them,  to  bring  them  to  shame. 
Secret  affairs  are  being  carried  on  in  the  house ;  strange 
people  are  standing  in  the  passage.     The  patient  ascertains 


286  DEMENTIA    PR/ECOX 

that  his  things  are  being  stolen,  that  a  "  secret  domiciliary 
visit "  was  held.  The  lock  is  forced  ;  his  boxes  have  been 
broken  open,  his  things  rummaged  through,  thrown  pell-mell, 
the  furniture  displaced.  His  bed  is  dirty  ;  his  clothes  are 
torn  ;  the  stove  is  being  blocked  up,  bad  air  let  into  the 
room,  the  water  suddenly  turned  off;  letters  are  being 
suppressed.  The  beer  causes  colic,  the  bread  a  burning 
in  the  brain  ;  there  are  poisonous  vapours  in  the  house ; 
there  is  a  suspicious  powder  in  the  bed  ;  the  doctor  gives 
a  blue  medicine  which  without  doubt  contains  prussic  acid 
and  is  intended  to  cause  the  death  of  the  patient.  In 
consequence  of  this  the  patient  feels  himself  "spied  on" 
everywhere  and  threatened,  not  safe  even  with  locked  doors  ; 
it  is  an  unparalleled  hounding,  fraud,  and  deceit,  "  the  whole 
affair  is  known  in  the  town."  "  There's  a  constant  uproar," 
declared  a  patient.  Obviously  there  exists  a  regular  con- 
spiracy that  carries  on  the  persecution  ;  sometimes  it  is  the 
social  democrats,  the  "  red  guard,"  sometimes  the  Free- 
masons, .sometimes  the  Jesuits,  the  Catholics,  the  spiritualists, 
the  German  Emperor,  the  "central  union,"  the  members  of 
the  club,  the  neighbours,  the  relatives,  the  wife,  but  especially 
former  mistresses,  who  cause  all  the  mischief. 

Hallucinations. — After  this  extremely  tormenting  state 
of  distrust,  uncertainty,  and  tension  has  continued  as  a  rule 
for  years,  real  hallucinations  usually  appear  also,  especially 
those  of  hearing.  The  patient  hears  whistling,  false  notes, 
weird  noises,  disapproving  remarks,  abusive  epithets,  threats. 
There  is  whispering  going  on,  telegraphy,  speaking  through 
the  telephone.  A  patient  ascertained  that  the  hallucinations 
ceased  on  his  ears  being  stopped,  another  that  they  were 
present  only  at  home  but  not  when  he  was  out  walking  ; 
both  drew  therefrom  the  wrong  conclusion,  that  it  could  not 
be  a  case  of  mistake.  Jews  scream  after  the  patient  on  the 
street  ;  people  speak  about  him,  call  him  foolish,  a  black- 
guard, filthy  beast,  old  wretch,  simpleton,  court-prostitute, 
a  bad  lot,  rascal,  ragamuffin,  criminal  ;  he  is  accused  of 
masturbation,  of  murder ;  it  is  asserted  that  he  is  impotent, 
that  he  is  sexually  filthy,  that  he  brought  his  parents  to  the 
grave  ;  his  son  has  been  killed.  A  female  patient  heard  her 
husband  and  her  son  lamenting  "  as  if  they  were  lying  in  the 
tower  of  purgatory  undergoing  penance "  ;  another  noticed 
that  she  was  jeered  at  because  of  her  alleged  sexual 
insatiability  ;  "  It  went  like  wildfire."  Everyone  abuses  and 
persecutes  him,  everyone  knows  all  the  circumstances  of  the 
patient  accurately.  Sometimes  it  is  not  a  case  of  sensory 
perceptions,  but  of  "spiritual  calls,"  "inspirations,"  "the  play 


PARAPHRENIA  287 

of  thought,"  "  thought  dialogue."  The  patients  are  made 
capable  of  that  by  hypnosis,  are  spiritually  questioned,  to 
which  questioning  they  answer  aloud  or  perhaps  only 
inwardly.  Now  and  then  they  notice  their  thoughts  becoming 
loud  ;  others  can  hear  it.  A  patient  thought  that  his 
neighbours  would  be  very  much  annoyed  with  his  thoughts 
being  said  aloud ;  another  heard  his  thoughts  whistled  after 
him  by  locomotives.  The  voices  also  perhaps  speak  in  the 
thoughts  of  the  patient,  criticize  him,  accompany  his  actions 
with  remarks. 

Hallucinations  of  other  senses  play  an  essentially  smaller 
part.  The  patient  is  "  fooled  with  visions,"  sees  skeletons, 
the  devil,  people  who  are  dead,  the  Virgin  Mary,  bleeding 
sacramental  bread,  naked  women.  To  a  female  patient  the 
faces  of  people  appeared  changed  ;  she  thought  that  people 
had  put  on  masks  or  other  heads.  Food  tastes  abominably, 
stinks;  the  house  is  filled  with  peculiar  smells;  the  clean 
linen  smells  of  a  chemist's  shop.  A  patient  complained  of 
unnatural  and  painful  sensations,  felt  mysterious  stabs  as  of 
a  dagger,  thought  that  Satan  was  spitting  on  him  ;  another 
felt  himself  struck,  rushed  upon,  pushed  about ;  a  woman 
thought  that  she  was  being  photographed  with  Rontgen  rays. 
Female  patients  have  sensations,  pulling  in  the  genitals,  feel 
themselves  spiritually  married. 

Ideas  of  Influence. — The  idea,  which  occurs  not  infre- 
quently, of  hypnotic,  magnetic,  electric  influences,  may  like- 
wise be  frequently  connected  with  bodily  dysaesthesiae,  sharp 
pains,  twitchings,  dragging  pains,  transmission  of  currents. 
Many  patients  make  statements  about  influences  on  will. 
Suggestions  are  given  to  them  by  magnetism  ;  people  want 
to  have  their  thoughts  ;  people  who  are  dead  tell  them  what 
they  must  do.  A  female  patient  felt  that  a  count  had  got 
her  in  his  power  ;  she  was  as  if  paralyzed  and  must  obey  him, 
she  could  not  eat  at  meal-times,  became  hungry  at  the  wrong 
time,  felt  herself  forced  to  buy  clothes  against  her  will ;  she 
was  not  able  to  love  her  mistress  any  more,  she  had  to  be 
impolite  to  her.  A  patient  declared  that  he  would  be  forced 
to  do  certain  actions  but  would  only  yield  in  insignificant 
things.  Another  thought  that  his  will  was  being  led : 
"  Someone  wants  to  do  something  to  me.  The  whole  force 
and  persuasion  from  an  unknown  part — it  is  forced  on  me 
that  I  must  think  myself  greater  than  I  really  am  or  was  in 
everyday  life  till  now." 

Exaltation. — When  the  delusion  of  persecution  has  con- 
tinued for  a  number  of  years  and  has  been  developing  by 
slow  progression  or,  as  happens  much  more  rarely,  after  the 


288  DEMENTIA    PR.tCOX 

disease  has  existed  for  only  a  short  time,  or  in  the  beginning 
of  it,  the  patient  produces,  sometimes  rather  suddenly, 
exalted  fdeas.  At  first  they  may  keep  within  fairly  modest 
bounds.  After  being  ill  for  some  years  a  woman  directed  a 
letter  to  the  emperor  with  the  inquiry  how  she  could  be  rid 
of  her  husband  ;  later  she  praised  her  own  brilliant  talk,  her 
voice  clear  as  a  bell,  her  fine  tact,  her  high  endowment. 
Another  female  patient,  who  felt  herself  very  much  annoyed, 
thought  that  she  must  have  a  peculiar  power  in  her  eyes 
because  people  could  not  look  at  her.  A  third,  after  being 
persecuted  for  six  years,  supposed  that  some  highly-placed 
personage  must  be  behind  it  all ;  a  patient  asserted  suddenly, 
after  he  had  suffered  extreme  torment  for  twent}'  \ears,  that 
some  of  his  fellow-patients  were  marquises  and  princes,  and 
he  began  to  treat  them  with  special  reverence  and  to  kiss 
their  hands. 

Very  commonly  the  patients  make  claims  to  money. 
From  some  source  or  another  large  sums  should  come  to 
them  which  are  being  kept  back  ;  they  have  been  left  an 
inheritance  which  has  been  suppressed.  A  patient  thought 
that  by  going  round  "circular  paths  '  he  would  earn  large 
sums,  and  daily  he  sought  such  paths  and  hoped  so  to  acquire 
about  30,000  marks  a  month,  which,  he  assumed,  would  be 
deposited  for  him  regularl)'  in  the  bank.  A  female  patient 
thought  there  and  then-  that  she  must  have  an  income  ; 
another  was  convinced  that  an  archduke  had  settled  some 
money  on  her  for  her  marriage.  Apparently  the)-  derive 
their  knowledge  of  such  things  most  frequently  from  hallu- 
cinations of  hearing  in  which  their  secret  wishes  come  to 
expression. 

In  a  further  group  of  cases  it  is  an  affair  oi  erotic  relations 
with  highly-placed  persons.  The  patient  notices  that  a  lady 
of  distinction  is  interested  in  him  ;  a  picture  postcard  which 
he  receives  is  obviously  from  her  ;  highly-placed  persons 
approach  him  in  all  sorts  of  disguise.  A  duke  made  known 
to  a  female  patient  by  hypnotic  ways  that  he  wished  inter- 
course with  her  ;  later  she  had  "  thoughts  of  love,"  that  a 
married  man  wished  to  marry  her,  and  she  made  all  the 
preparations  for  her  marriage.  At  the  same  time  high- 
sounding  titles  are  often  attributed  to  the  loved  ones. 
The  man  last  mentioned  became  a  baron  to  the  patient. 
Another  female  patient  wrote  letters  to  a  man,  also  already 
married,  with  the  address,  "Peter  the  Great  of  Russia,  in- 
cognito," and  then  made  complaints  at  the  post-office  that 
the  letters  were  not  dispatched.  Others  exalt  their  enemies. 
A  patient  threatened  that  with  the  help  of  the  pope  he  would 


PARAPHRENIA  ^  289 

put  Bismarck  in  chains ;  another  supposed  that  the  main- 
spring of  all  the  troubles  that  came  upon  him  was  William  II., 
whom  he  regarded  as  his  personal  enemy. 

But  most  frequently  by  far  the  exaltation  in  rank  concerns 
the  patient  himself.  He  observes  that  he  is  being  greeted  by 
gentlemen  of  rank,  that  sentries  show  him  marks  of  respect, 
that  he  is  treated  with  peculiar  distinction  ;  the  policeman 
who  travels  everywhere  after  him  is  appointed  by  the 
Emperor  for  his  protection.  Someone  or  other  addresses 
him  as  Count  or  Prince ;  the  waiters  speak  of  Highness,  of 
Elector ;  immediately  on  his  appearance  they  have  a  fresh 
barrel  broached  ;  as  soon  as  he  begins  to  eat  the  lights  go  up. 
He  perceives  that  the  Emperor  is  interested  in  him,  that 
princes  also  are  in  the  affair,  that  aristocratic  ladies  send  him 
letters  and  presents,  which  in  an  infamous  way  are  suppressed  ; 
a  patient  thought  that  he  had  himself  seen  the  ladies  throwing 
letters  into  the  letter-box.  Someone  makes  known  to  the 
patient  that  coins  with  the  likenesses  of  his  ancestors  are  in 
existence  ;  he  hears  allusions  and  learns  through  the  telephone 
that  a  patent  of  nobility  has  been  awarded  to  him,  that  at  mid- 
night he  will  be  publicly  proclaimed  a  Count  of  the  Empire. 
It  becomes  clear  to  him  that  he  is  of  high  descent,  that  his 
ancestors  have  played  a  great  role,  that  he  possesses  great 
merit  and  rights.  He  can  display  gigantic  capacity  and 
knowledge,  feels  himself  a  political  personage  of  the  first 
rank,  a  member  of  the  House  of  Lords  and  Vice-chancellor  of 
the  Empire,  a  relative  of  the  reigning  House,  indeed  the 
rightful  ruler  of  the  country  himself;  "  Indeed  the  whole 
world  knows  that,"  said  a  patient.  He  is  the  "King's  bastard," 
son  of  the  Emperor  Frederick,  step-brother  of  Prince  Charles 
P'rederick,  is  in  communication  with  all  monarchs,  will  marry 
Princess  Katherine  of  Russia.  A  patient  declared  that  he 
was  emperor  and  pope  in  one  person,  ruler  of  the  whole  world, 
later  also  that  he  was  immortal,  that  he  had  driven  the 
capacity  of  decomposition  out  of  his  body  by  salt,  and  that 
he  was  a  unique  thing  among  human  beings.  A  glimpse 
into  this  train  of  thought  is  afforded  by  the  following  frag- 
ment of  a  letter  : — 

"  Distress,  grief,  care  and  doubt  make  me  have  the  most  unrefresh- 
ing  nights.  I  cannot  be  indifferent,  and  so  the  dumb,  obdurate  world 
is  an  oppressive  burden  to  me,  even  though  the  star  of  my  bliss  is  as 
large  and  glorious  as  the  sun  in  the  firmament.  The  black  spectre  of 
doubt,  which  often  haunted  me  so  dreadfully  last  year,  causes  me  the 
question  of  the  whole  future,  namely,  immortality  1  Dear  K.  you  will 
also  be  frightened  about  it,  because  no  one  as  yet  has  remained  in  the 
world.  But  it  is  also  evident  and  not  to  be  refuted,  that  also  as  yet  no 
one  has  been  endowed  with  my  qualities.     For  this  reason  it  is  certainly 

T 


290  ,        DEMENTIA    PR/ECOX 

not  absurd  to  think  about  it  and  to  talk  loud  out,  consequently  even  to 
believe,  and  the  doubt,  when  it  comes  upon  me,  is  no  wickedness  and 
no  sin.  I  have  not  called  forth  this  thought  ;  it  came  upon  me  suddenly 
as  long  as  two  years  ago,  in  a  moment  when  I  went  past  the  well  in  the 
garden,  and  immediately  took  complete  possession  of  me,  so  that  I  was 
not  able  to  ward  it  off.  ...  I  am  already  advanced  to  the  half  of  the 
usual  age,  and  who  has  thought  of  laying  down  arms  and  surrendering 
at  discretion  ?  Yes,  certainly  the  world  has  enough  cause  to  defy  the 
Messiah  !  Still  with  the  truth  it  is  to  be  hoped  that  I  shall  come  out 
top  over  all  fraud,  and  that  everyone  must  acknowledge  that  I  am  the 
Lord,  as  Pharaoh  learned.  Let  it  be  said,  for  dying  I  have  not  time  so 
soon  ;  I  must  first  beget  or  create  looo  million  children,  that  is  soldiers, 
and  so  they  may  defy.  ..." 

In  a  small  number  of  cases  the  exalted  ideas  acquire  a 
somewhat  i-eligious  content,  as  already  in  the  example  just 
quoted.  The  patient  is  sent  by  God,  is  the  protestant 
Joshua,  speaks  words  of  divine  authority.  \  female  patient 
declared  that  she  was  a  saint,  she  had  the  insight  of  a  seer, 
could  read  the  hearts  of  men,  felt  beforehand  if  anyone 
died,  understood  all  the  four  faculties,  was  comforted  by 
God  ;  another  was  called  the  bride  of  Christ.  These 
delusions  are  often  reflected  in  all  sorts  of  hallucinations. 
The  patient  mentioned  saw  the  child  Jesus  beside  her  bed  ; 
the  light  of  the  monstrance  fell  on  her.  She  heard  God's 
voice  which  gave  her  commands  and  imparted  answers  to 
thought-questions  ;  she  felt  at  night  a  warm  breath  and  a 
face  beside  her,  perceived  copulation  and  then  heard  the 
child  speak  in  her  belly.  The  patient,  from  whom  the 
document  quoted  originates,  saw  how  the  pictures  of  saints 
nodded  to  him,  how  a  radiance  shone  from  his  forehead ; 
he  heard  the  voice  of  his  guardian  angel,  felt  an  invisible 
hand  on  his  head,  the  pricks  of  the  crown  of  thorns  on  his 
skull.  Other  patients  hear  hints  that  they  are  Emperor  or 
Crown  Prince,  that  they  are  in  the  middle  of  a  pile  of  money, 
are  to  get  one  to  two  millions ;  a  female  patient  heard 
"  supernatural  things"  ;  it  was  said,  "Thou  shalt  be  the  lion 
for  the  sin."  On  the  other  hand  harmless  perceptions  are 
interpreted  according  to  the  megalomania.  A  patient 
asserted  that  the  reigning  prince  had  appeared  in  a  restaurant 
for  his  sake  disguised  as  a  "  field-worker " ;  another  saw  a 
landlord  make  movements  with  his  fingers  and  a  guest 
shake  his  head  in  reply;  he  concluded  from  this  that  they 
wanted  to  signify  to  him  that  he  should  accept  the  sum 
offered  to  him. 

Ideas  of  exaltation  and  persecution  frequently  come  into 
a  certain  relation  to  each  other.  Their  conjunction  is  here, 
as  in  several  other  diseases,  so  frequent  that  it  can  hardly  be 


PARAPHRENIA  291 

doubted  that  there  is  an  inner  connection  between  the  two. 
It  is  usual  to  represent  it  in  this  way,  that  the  elaborate 
arrangements  which  are  made  to  injure  them  cause  the 
patients  to  think  that  there  must  be  some  special  reason 
connected  with  their  person,  or  that  the  opposition,  which 
stands  in  the  way  of  the  realization  of  their  delusion  of  great- 
ness, engenders  ideas  of  persecution.  Sometimes  indeed  the 
patients  give  utterance  to  ideas  which  seem  to  point  to  such 
trains  of  thought.  People  are  trying  to  get  them  out  of  the 
way,  in  order  to  be  able  to  take  possession  of  their  great 
inheritance;  people  wish  by  "court  intrigues"  to  hinder 
them  from  making  an  aristocratic  marriage ;  they  are  to  be 
made  willing  by  the  traps  laid  for  them  to  marry  their 
persecutor.  A  female  patient  thought  that  her  relatives 
wished  to  hinder  her  from  marrying  till  she  could  no  longer 
have  children,  in  order  that  she  might  become  a  rich  old 
aunt  ;  a  patient  who  considered  himself  the  rightful  King  of 
Bavaria  stated  that  the  plebs  were  hostile  to  him  ;  others  are 
persecuted  in  order  to  prevent  them  from  making  known  their 
just  claims.  Meantime  the  attempts  at  explanation  proffered 
here  by  the  patients,  which  moreover  often  completely  break 
down,  are  hardly  more  than  reasons  thought  out  after  the 
event ;  otherwise,  indeed,  they  would  come  to  the  surface 
much  sooner.  As  we  shall  see  later  in  the  delusion  of 
pardon  in  prisoners,  a  profound  emotional  disturbance  last- 
ing for  a  very  long  time  engenders  by  itself  the  tendency  in 
some  measure  to  take  flight  from  inexorable  reality  to  a  world 
of  pleasing  illusions,  a  process  that  surely  signifies  a  certain 
weakening  of  the  psychic  power  of  resistance.  As  it  has  to 
do  with  a  progressive  morbid  process,  it  could  be  understood 
that  the  exalted  ideas  as  a  rule  do  not  usually  appear  till  the 
patient  has  become  prepared  in  the  hopeless  struggle  against 
hostile  powers. 

The  Perception  of  the  patients  is  never  disordered.  They 
are  clear  about  their  surroundings  and  their  position,  if  the 
misinterpretations  caused  by  delusions  are  not  considered. 
Understanding  of  the  disease  is  completely  absent,  though  a 
certain  rnorbid  feeling  appears  often  to  be  present  at  least  at 
the  beginning.  The  substance  of  the  hallucinations  of 
hearing  point  to  that ;  it  is  not  infrequently  related  to 
psychic  disorder:  "That's  where  the  silly  woman  lives," 
"  We're  going  to  take  him  to  the  mad-house."  Many 
patients  feel  themselves  "driven  to  madness,"  made  to  have 
brain  disease,  made  stupid,  their  enemies  are  to  make  them 
lose  their  understanding ;  others  try  all  sorts  of  experiments 
to   find    out   whether   it   is  a  case  of  hallucinations  or  real 


292  DEMENTIA    PR/ECOX 

perceptions.  In  the  end,  however,  healthy  deliberation  is 
invariably  overpowered  by  the  morbid  influences,  and  the 
patient  remains  completely  deaf  to  reasoning.  "  I  ride  my 
nag  and  I  do  not  give  the  reins  to  anyone  else,"  a  patient 
declared.  A  woman  said  "  If  I  imagine  everything,  then  I 
admit  that  I  am  a  regular  fool,"  but  in  spite  of  this  she  was 
not  able  to  correct  her  ideas  of  persecution  ;  she  looked  on 
the  supposed  bad  treatment  in  the  institution  as  a  sort  of 
method  of  cure  by  which  she  should  become  accustomed  to 
the  persecutions  outside. 

Pseudo-memories. — Memory  and  retention  do  not  in 
general  exhibit  any  disorders,  but  delusional  pseudo-memories 
not  infrequently  come  under  observation.  The  patients 
report  that  already  in  their  youth  they  were  persecuted, 
that  their  experiences  were  already  made  public  previously 
in  the  newspapers,  were  made  known  to  them,  usually  with 
all  details  ;  formerly  they  had  not  paid  any  attention  to  it, 
but  it  now  occurs  to  them.  A  female  patient  asserted  that 
she  had  repeatedly  been  hypnotized  and  assaulted,  but  had  no 
idea  of  it  till  it  now  came  into  her  mind  again.  The  validity 
of  their  claims  has  formerly  been  confirmed  to  many  patients. 
A  patient  reported  that  already  in  school  he  was  addressed 
as  Prince  ;  his  grandfather  said  to  him  of  William  I.,  "  Joseph, 
that  is  your  grandfather."  Later  in  the  year  1886,  he  met 
the  Emperor  Frederick,  who  had  a  canula  in  his  throat ;  it 
was  said  to  him  that  was  his  father.  !t  was  made  very 
plain  to  him  everywhere  ;  his  mother  spoke  of  the  Crown 
Prince  ;  in  his  sponsor's  letter  there  was  a  large  sum  of 
money  ;  his  aunt  wrote  to  him  on  the  death  of  the  Emperor 
Frederick  ;  in  the  tramcar  someone  said,  "That  is  the  German 
Emperor."  It  was  said,  "Two  emperors  at  the  same  time, 
that  was  a  difficult  birth,"  from  which  he  concluded  that  he 
must  have  had  a  twin-brother. 

Exactly  those  kinds  of  delusional  experience  which  one 
would  at  first  be  inclined  to  trace  back  to  hallucinations  often 
prove  on  more  exact  examination  to  be  pseudo-memories. 
A  patient  narrated  that  many  years  ago  a  strange  man  had 
strewn  poisonous  powder  on  his  forehead  through  the  crack 
of  the  door;  at  the  same  time  he  heard  a  gold  piece  jingle 
as  a  sign  that  the  man  was  hired  by  his  enemies.  Another 
patient  affirmed  that  solemn  promises  were  made  to  him 
in  Parliament  from  the  ministerial  bench  ;  a  third  repeated 
a  host  of  long  conversations,  which  were  connected  with  his 
claims  to  an  inheritance,  word  for  word  with  such  detail,  as 
is  never  possible  in  real  hallucinations,  but  for  pseudo- 
memories  is  characteristic.     I  quote  here  an  example  from  his 


PARAPHRENIA  293 

numerous   notes  of  the  conversations  alleged    to   have  been 
heard  by  him  relating  to  his  claims  : — 

"  On  the  2nd  February  I  was  at  the  funeral  of  A.  at  the  Auerfried 
Cemetery.  It  was  half-past  two  o'clock  when  I  arrived.  South  from  the 
old  mortuary  four  people  preceded  me.  Furthest  to  the  left  there  was 
Joseph  R.,  then  his  wife,  beside  her  Mrs  S.,  and  furthest  to  the  right  a 
man  unknown  to  me  with  his  brown  cloak.  I  was  walking  only  a  few 
steps  behind  them,  and  heard  every  word  that  was  said.  Mrs  S.  said, 
'Oh,  how  P.  (name  of  the  patient)  looks;  it's  a  veritable  pity,  and  he  was 
once  such  a  capable  workman  ;  how  they  have  ruined  him  ;  that  is  an 
abominable  injustice.'  Mrs  R.,  'And  now  they  want  to  keep  back  his 
money  from  him  too,  and  he  is  so  much  in  need  of  it  ;  just  look  at  him, 
how  he  looks,  so  pitiable  ! '  R.,  '  Of  course  they  would  not  want  to  give 
him  the  money  ;  they  say  he  does  not  need  it,  but  they  must  certainly 
give  it  to  him  ;  but  it  will  still  come  to  light ;  then  they  will  be  well 
punished.'  The  man  on  the  right,  '  Then  doesn't  he  know  anything  of  the 
business  ?'  Mrs  S.,  '  He  does  know  something  but  not  rightly.'" 

Mood  is  at  first  for  the  most  part  anxious,  depressed, 
even  despairing,  but  then  becomes  more  and  more  suspicious, 
strained,  hostile,  threatening.  Later,  when  the  exalted  ideas 
come  more  distinctly  into  the  foreground,  the  patients 
become  self-conscious,  haughty,  scornful.  They  withdraw 
themselves  from  the  people  round  them,  avoid  intercourse,  go 
lonely  ways,  appear  sometimes  brusque  and  unapproachable, 
sometimes  formally  polite  and  dignified,  but  from  time  to 
time  may  also,  where  the  delusional  attitude  to  their 
surroundings  does  not  come  into  consideration,  be  pleasant 
and  accesiBible.  In  their  spoken  or  written  statements  they 
are  usually  skilful  and  ready,  give  a  connected  and  reasonable 
account  of  things,  refute  objections,  and  in  doing  so  readily 
become  impassioned  and  excited,  or  they  are  repellent,  will 
not  admit  any  explanation,  declare  that  it  is  superfluous, 
everything  is  already  known  without  it. 

The  Activities  of  the  patients  are  influenced  in  the  most 
decided  way  by  their  delusions.  It  is  true  that  many 
patients  may  continue  to  live  for  many  years  in  their  usual 
circumstances  without  specially  severe  disorders,  but  at  the 
same  time  their  whole  conduct  very  soon  shows  the  deep- 
reaching  morbid  change  which  has  been  accomplished  in 
them.  Apart  from  the  fact  that  they  shut  themselves  up  and 
become  gloomy  and  taciturn,  they  fall  sooner  or  later  into 
all  kinds  of  disputes.  They  carry  on  loud  soliloquies,  they 
drum  and  knock  on  the  furniture  in  the  room,  are  irritated 
without  recognizable  cause  ;  they  are  abusive,  they  threaten, 
they  make  a  noise  at  night.  Many  patients  defend  them- 
selves in  despair  against  the  voices,  stop  their  ears,  whistle  or 
scream  loudly  to  drown  the  sound  of  them.     The  voices  said 


294  DEMENTIA    PRECOX 

to  a  female  patient  that  she  should  just  be  violently  abusive; 
she  was  so  aloud  or  in  thought;  that  helped.  A  patient  was 
forced  by  the  voices  to  continual  answering  by  the  remark, 
"  Silence  gives  consent." 

Often  there  are  sudden  attacks  of  anxiety.  A  patient 
called  loudly  for  help  at  night,  barricaded  himself  in  his 
room,  and  passed  a  motion  on  the  floor  because  he  did  not 
dare  to  go  to  the  water-closet.  The  patients  frequently 
change  situation  and  place  of  residence  ;  a  female  patient  for 
years  moved  from  town  to  town  and  always  after  a  few 
months  made  the  discovery  that  she  could  not  continue  in 
her  new  home  because  everyone  was  already  initiated.  A 
patient  tried  to  lead  his  persecutors  astray  by  giving  a  false 
destination  aloud  on  going  out. 

Sometimes  it  comes  to  wholly  nonsensical  actions 
probably  caused  by  delusions.  A  female  patient  stood  for 
hours  in  the  sun,  washed  herself  in  the  water-closet,  picked 
the  skin  off  her  face  because  small  grains  of  sand-soap  had 
penetrated  it.  A  physician  left  his  faeces  on  the  table-cloth 
and  gargled  with  his  urine.  Very  commonly  after  some  time 
the  patients  apply  to  the  police,  beg  for  protection  against 
the  annoyance,  ask  for  an  explanation  of  what  they  are 
accused  of,  put  advertisements  in  the  newspapers  to  defend 
themselves  against  supposed  slanders,  appeal  to  the  public 
with  a  cry  of  distress.  A  patient  ran  through  the  streets  in 
his  shirt  in  order  to  force  admission  to  an  institution  for  the 
insane  for  the  verification  of  his  mental  state. 

An  idea  of  the  struggle  which  the  patients  go  through  is 
given  in  the  following  fragments  from  letters  which  a  patient 
threw  over  the  walls  of  the  institution  in  order  to  call  the 
attention  of  passers-by  to  his  circumstances  : 

"When  I  came  to  Munich  in  the  year  1875, 1  was  brought  by  force  to 
the  institution  for  the  insane  here,  for  fear  I  might  bring  a  complaint 
before  the  court,  although  according  to  a  medical  certificate  and  my 
certificate  of  service  I  was  physically  and  mentally  perfectly  healthy  and 
fit  for  work  and  no  one  could  complain  of  me.  As  appears  from  my  letters, 
complaints,  and  so  on,  my  freedom  is  taken  from  me  in  this  institution 
here  principally  for  the  purpose,  though  hitherto  without  success,  of 
destroying  in  every  possible  way  my  mental  and  physical  health,  for 
which  unprecedented  crime  the  persons  who  took  part  in  it  are  responsible. 
The  institution  for  the  insane  is  wrongfully  used  for  the  greatest  crimes 
and  serves  especially  the  particular  interests  of  unscrupulous  physicians. 
I  live  here  among  wholly  demoralized  people,  who  for  the  most  part  avoid 
work,  of  whom  several,  as  also  the  so-called  attendants,  gain  their  living 
by  continually  annoying  and  disturbing  me  by  all  sorts  of  misconduct 
and  noise.  .  .  .  The  superintendent  of  the  institution  avoids  less  and  less 
every  day  the  worst  means  to  disturb  me  continually  in  my  peace  and 
where  possible  to  get  opportunity  to  have  me  still  more  under  his  power. 


PARAPHRENIA  295 

Every  human  feeling  and  decency  are  here  trodden  under  foot.  The 
physicians  often  pretend  to  be  insane  and  to  confuse  nie  with  some  other 
person.  In  the  interest  of  order  and  justice  I  beg  everyone  to  interest 
himself  in  my  affairs  and  to  bring  them  to  public  discussion." 

Self-defence. — As  the  inward  tension  increases,  the 
patients  who  see  themselves  helpless  and  abandoned  to 
persecution,  often  undertake  self-defence.  They  call  the 
offending  individuals  to  account,  or  in  petitions  to  the 
Emperor  explain  the  whole  of  the  mean  fraud  which  is  being 
carried  on  with  them,  or  try  by  deliberate  attempts  to  escape 
from  the  detention  in  the  institution  for  the  insane.  They 
overwhelm  a  policeman  with  invective,  suddenly  box  the  ears 
of  a  harmless  neighbour  at  table,  by  whom  they  fancy  they 
are  abused,  throw  stones  at  the  passers-by,  and  finally  make 
dangerous  assaults  on  their  supposed  persecutors ;  they 
become,  as  the  French  alienists  call  it,  "  persecuteurs 
persecutes."  A  patient  shot  his  landlady  from  behind  as  she 
was  passing,  without  further  consideration,  because  he  was 
convinced  that  she  was  going  to  put  him  in  prison  and  incite 
others  to  murder  him  ;  she  had  rattled  with  the  keys  in  the 
morning,  carried  on  a  lively  conversation  with  some  neigh- 
bours who  *  were  sick  nurses,  made  signs  and  laughed 
sarcastically,  so  that  he  thought  he  was  in  the  greatest 
danger.  Some  patients  perpetrate  attempts  at  suicide  in 
order  to  escape  from  their  persecutors. 

The  exalted  ideas  may  lead  to  all  kinds  of  morbid  actions. 
The  patient  goes  to  the  bank  to  take  out  the  sum  standing 
to  his  credit,  tries  to  get  information  about  his  descent  at  the 
registrar's  office,  suddenly  makes  a  proposal  of  marriage, 
torments  in  every  possible  way  his  supposed  beloved,  who  in 
spite  of  all  refusals  still  continues  to  give  him  to  understand 
by  a  flower  that  he  is  welcome  to  her.  A  female  patient 
repeatedly  tried  to  force  her  way  late  in  the  evening  into  the 
house  of  a  married  man  to  whom  she  asserted  she  was 
"  civilly "  married,  and  desired  that  he  should  immediately 
send  away  his  wife  out  of  the  house  and  admit  her  to  his 
wife's  place.  Other  patients  give  conspicuously  large  sub- 
scriptions to  public  collections,  write  letters  to  highly-placed 
personages,  go  to  the  capital  of  the  country  to  pay  their 
respects  to  the  sovereign  or  to  bring  forward  their  claims  to 
the  throne.  A  female  patient  asked  the  reigning  prince  by 
letter  to  find  out  the  address  of  a  washerwoman  which  she 
had  not  been  able  to  get  at  the  police  office.  A  patient  had 
visiting-cards  printed  with  high-sounding  titles,  and  sent  tips 
to  the  policemen  who  had  saluted  him  most  respectfully  after 


296  DEMENTIA    PRyECOX 

his  supposed  elevation  to  the  rank  of  baron  ;  he  paid  visits 
to  the  most  varied  governmental  departments ;  he  gave 
advice  in  long  documents  about  home  and  foreign  politics, 
sketched  out  financial  plans,  appeared  uninvited  at  a  dinner 
of  the  federal  council.  Another  asked  the  French  minister 
Delcasse  to  place  ten  million  francs  at  his  disposal.  Many 
patients  are  very  fond  of  writing,  and  compose  comprehen- 
sive petitions  to  the  most  varied  authorities  and  personages 
not  only  about  their  own  business  but  also  about  all  possible 
other  questions — about  the  overworking  of  horses,  the  break- 
ing up  of  the  Sunday  rest,  the  question  of  prostitution,  plans 
for  the  improvement  of  the  world. 

The  Capacity  for  Work  of  the  patients  may  be  preserved 
for  a  long  time  fairly  well.  The  above-mentioned  patient 
who  was  about  to  shoot  his  landlady  remained,  in  spite  of  the 
delusion  of  persecution,  which  had  already  existed  for  ten 
years,  a  diligent  and  useful  worker.  Others,  after  being  ill 
for  decades,  still  draw  very  creditably,  write  poems,  produce 
contributions  for  magazines  ;  women  can  often  conduct  their 
household  to  complete  satisfaction.  A  peasant  boy  when  he 
felt  himself  called  to  be  ruler  of  the  world  acquired  a  certain 
amount  of  knowledge  of  the  Greek,  Italian,  Spanish,  Russian 
and  Latin  languages  one  after  the  other.  Nevertheless  by 
the  continued  inner  tension  and  excitement  the  capacity  for 
regulated  fruitful  work  in  most  cases  gradually  but  materially 
suffers  ;  the  frequent  change  of  situation  in  consequence  of 
the  ideas  of  persecution  also  works  unfavourably  in  this 
direction.  Many  patients  finally  give  up  serious  work  alto- 
gether, especially  if  exalted  ideas  begin  to  make  their  appear- 
ance ;  they  live  a  day  at  a  time,  read,  dream,  go  walks,  and 
wait  for  the  fulfilment  of  their  great  hopes. 

The  General  Course  of  the  malady  here  described  is,  as 
has  been  already  mentioned,  very  slow,  but  still  it  progresses 
fairly  continuously.  Fluctuations  of  the  state  seem  to 
appear  only  in  limited  measure.  It  is  true  that  the  patients, 
especially  in  immediate  connection  with  the  difficulties  of 
life,  are  at  times  more  excited  or  more  anxious,  and  are 
then  quieter  again,  but  of  real  disappearance  of  the  morbid 
phenomena  there  is  scarcely  a  question,  even  if  the  patients 
perhaps  are  able  temporarily  to  force  their  delusional  trains 
of  thought  into  the  background  or  at  least  to  conceal  them. 

In  the  course  of  decades,  however,  a  distinct  change  in 
the  whole  psychic  conduct  usually  makes  itself  felt.  It 
is  certainly  favoured  by  the  circumstance  that  the  patients 
because  of  their  peculiar  or  dangerous  actions  and  also  their 
behaviour,  after  a  shorter  or  longer   space  of  time,  usually 


PARAPHRENIA  297 

have  to  be  placed  in  an  institution  and  often  suffer  extremely 
by  the  deprivation  of  freedom.  Their  delusions,  which 
receive  fresh  nourishment  from  it,  become  in  this  way 
gradually  more  nonsensical  and  more  extraordinary.  The 
patients  are  in  a  den  of  murderers,  feel  themselves  worried 
in  every  possible  way,  are  massacred  by  day  and  by  night, 
assaulted,  spied  on  with  the  microphone,  chloroformed, 
tormented  by  Satan,  suffocated  by  the  stinking  current 
and  by  electric  poison  rays.  The  physicians  are  in  league 
with  their  persecutors ;  they  are  being  inoculated  with 
syphilis  ;  varicose  veins  and  furuncles  are  being  produced 
in  them  ;  their  bones  are  being  torn  asunder  electrically  ; 
nocturnal  emissions  are  caused  ;  attempts  are  made  on 
their  life  with  unscrupulous  fury ;  they  are  stupefied  by 
poisonous  pillows.  In  the  institution  there  are  secret 
passages ;  patients  are  slaughtered  and  devoured  ;  the 
Emperor  is  deposed,  dead  ;  a  puppet  has  been  put  in  his 
place;  King  Ludwig  II.  is  still  living.  A  patient  made 
the  announcement  that  a  great  assemblage  of  princes  was 
taking  place,  in  which  the  Prince  Regent  was  kept  prisoner, 
and  people  were  continually  being  shot.  On  the  other  hand 
the  patient  has  risen  by  degrees  to  always  higher  dignities, 
is  in  communication  with  all  monarchs,  has  made  1600 
prophecies  which  have  all  been  fulfilled ;  he  is  the  colleague 
of  Jesus,  the  Lord  God  Himself,  demands  untold  millions 
as  compensation.  His  fellow-patients  are  counts  and  princes, 
aristocratic  ladies  who  live  in  the  institution  on  his  account ; 
the  nurses  are  hermaphrodites ;  the  physicians  appear  in 
different  forms.  The  patient  proclaims  death  sentences,  and 
threatens  to  put  everyone  in  jail,  to  make  the  military 
advance,  and  to  have  the  institution  shot  to  the  foundation. 

In  his  behaviour  he  becomes  assuming  and  flares  up 
easily ;  he  overwhelms  visitors  with  prolix  explanations 
often  rather  vague ;  at  times  he  is  abusive,  indulging  in 
the  strongest  language ;  he  finds  fault,  he  is  destructive 
and  aggressive.  Or  he  shuts  himself  up,  goes  his  own 
way,  buries  himself  in  monotonous  occupations,  produces 
comprehensive  documents  with  endless  repetition  of  the 
same  strains  of  thought,  sometimes  in  bombastic  style, 
with  peculiar  orthography  and  many  flourishes  in  the 
calligraphy  ;  one  patient  painted  lines  or  innumerable  single 
letters.  The  form  of  expression  occasionally  becomes 
capricious,  especially  in  excitement,  the  manner  of  speech 
affected.  A  patient  thought  that  it  was  "  a  business  got 
up  that  way  by  instigation "  ;  another  on  being  accosted 
said    that   he   did    not   let   himself  be   "  informed,"   he   did 


298  DEMENTIA   PRECOX 

not  give  up  any  right  ;  a  female  patient  declared  that  she 
did  not  want  the  obscene  cross ;  another  wrote  :  "  All  in  all, 
also  the  cutting  short  or  the  complete  cutting  off  of  such  to 
me  honestly  most  happy  time  and  times,  which  already  since 
the  year  1889  by  God's  grace  was  thus  at  our  disposal,  or 
thus  becoming  and  shortened  by  such  measures  of  arbitrary 
power  and  judgments.  It  is  my  last  summons."  A  third 
asserted  that  she  was  subject  to  the  annoyance  of  a  vehmgericht 
and  sun-dial.  Playing  with  syllables  also  occurs;  a  lady 
analysed  names  into  their  syllables,  distorted  them,  and  said, 
"  The  name  says  everything  (Esser-Ex-sex-Ex-sachs)." 

In  spite  of  all  this  the  patients  remain,  even  after  their 
malady  has  continued  for  twenty  to  thirty  years,  clear  on  the 
whole  about  time  and  place  as  well  as  about  their  position,  as 
far  as  their  delusions  do  not  play  any  part,  and  also  rational 
in  their  behaviour,  here  also  apart  from  delusional  influences. 
They  are  able  to  occupy  themselves,  to  take  up  an  attitude 
to  the  events  going  on  around  them,  are  even  accessible  and 
pleasant  towards  strangers  who  have  no  relation  to  their 
delusions,  give  information  in  a  connected  and  compre- 
hensible way.  But  above  everything  they  do  not  appear 
dull  or  silly,  but  are  always  interested,  cheerful,  and  vivacious. 
Several  of  my  patients  knew  how  to  convince  completely 
one  or  other  unreasoning  member  of  their  family  of  the 
reality  of  the  persecutions  and  of  their  high  claims. 

The  Issue  of  the  malady  is  a  psychic  decline  with  per- 
sistent delusions  and  usually  also  hallucinations  without 
specially  striking  independent  disorders  of  volition  and  with- 
out emotional  dulness.  Recovery  does  not  appear  to  occur  ; 
yet  it  may  certainly  be  possible  that  isolated  cases  recover 
without  being  recognized.  On  the  other  hand  higher  grades 
of  dementia  are  not  reached  ;  even  after  very  long  duration  of 
the  disease,  extending  twenty  to  thirty  years  or  more,  it  does 
not  produce  real  disintegration  of  psychic  personality. 

The  share  of  the  male  sex  was  60  per  cent,  in  my  cases. 
Rather  more  than  half  of  the  patients  were  at  the  beginning 
of  the  malady  between  the  thirtieth  and  the  fortieth  year, 
a  little  over  20  per  cent,  between  the  fortieth  and  fiftieth 
year ;  only  isolated  cases  began  before  the  twenty-fifth  or 
after  the  fiftieth  year.  It  is  true,  accordingly,  for  this  disease 
also  what  we  were  able  to  establish  in  the  delusional  forms 
of  dementia  pnecox,  that  it  attains  to  development  only  in 
riper  years.  This  circumstance  might  arouse  the  suspicion 
that  the  clinical  details  perhaps  depend  more  on  the  manner 
of  reaction  of  the  developed  personality  than  on  the  peculi- 
arity of  the  fundamental  morbid  process. 


PARAPHRENIA  299 

Specially  severe  hereditary  taint  did  not  seem  to  me  to 
be  present ;  I  would,  however,  lay  no  weight  on  this,  on  the 
one  hand  considering  the  relatively  small  number  of  cases 
and  also  because  of  the  circumstance  that  many  of  them 
reached  back  thirty  to  forty  years  and  the  previous  history 
was  therefore  frequently  incomplete.  In  a  series  of  patients 
there  was  a  report  of  peculiar  disposition.  Some  were 
described  as  very  pious,  others  as  inclined  to  depression  or 
as  weak  and  sensitive,  one  as  spiteful  and  malicious.  One 
patient  was  regarded  as  very  gifted ;  another  was  a  clever 
author  inclining  to  be  visionary ;  a  third  an  excellent  chess- 
player. These  experiences  witness  against  the  view  of 
Magnan,  who  has  tried  to  separate  his  "delire  chronique" 
from  the  "  mental  disorders  of  the  degenerate."  The  latter 
are  said  to  be  distinguished  by  rapid  development,  frequent 
change  of  state,  conjunction  of  delusions  of  different  kinds, 
and  disappearance  of  auditory  hallucinations  relatively  to 
those  of  the  other  senses.  I  have  not  been  able  to  convince 
myself  that  these  differences  can  be  placed  in  causal  relation 
to  the  existence  or  absence  of  degeneration.  External  causes 
for  the  outbreak  of  the  disease  I  have  scarcely  ever  found 
recorded  ;  in  isolated  cases  the  misuse  of  alcohol  or  infection 
by  syphilis  had  preceded.  We  shall,  therefore,  bie  able  to 
assume  rightfully  that  the  disease  is  engendered  by  internal 
causes,  but  of  what  kind  it  is  certainly  not  possible  for  us 
at  present  even  to  make  a  hypothesis. 

Delimitation. — It  is  above  everything  the  permanent 
preservation  of  the  psychic  personality  that  has  caused  me 
to  delimit  the  morbid  group  here  described  from  Xhe.  paranoid 
forms  of  dementia  pra^cox.  Certainly  doubt  is  allowable 
whether  this  standpoint  is  justified.  In  dementia  pra^cox 
also,  especially  in  the  paranoid  forms,  the  disintegration  of 
the  personality  may  not  take  place,  as  we  have  seen  in 
hallucinatory  or  paranoid  weak  -  mindedness.  But  it  is 
obvious  that  in  those  terminal  states  we  have  to  do  with 
morbid  processes  which  have  run  their  course  and  ended  in 
recovery  with  defect,  and  just  on  that  account  these  cases 
have  not  progressed  to  the  more  severe  forms  of  dementia 
such  as  form  the  issue  of  other  paranoid  cases  of  dementia 
precox.  We  may  well  imagine,  and  may  occasionally  even 
really  experience  it,  that  a  fresh  outbreak  of  the  disease 
may  yet  transform  the  hallucinatory  or  paranoid  weak- 
mindedness  into  a  drivelling,  silly,  negativistic  or  dull 
dementia. 

It  appears  that  the  circumstances  are,  however,  somewhat 
different   here.      The   disease   does   not   after   a   few   years 


300  DEMENTIA  PRECOX 

remain  stationary  and  then  leave  behind  it  an  essentially 
uniform  and  permanent  terminal  state,  but  it  progresses, 
even  though  very  slowly,  even  after  one  or  two  decades, 
continuously,  and  almost  never,  or  only  after  an  uncommonly 
long  duration,  leads  to  an  unchanging  terminal  state  which, 
however,  still  scarcely  injures  the  inner  connection  of  the 
psychic  personality.  Against  this  it  can  certainly  be  said 
that  we  separated  out  only  the  cases  of  dementia  pr.tcox 
which  have  a  very  slow  and  relatively  mild  course,  and  that 
indications  of  the  disorders  which  we  met  there  are  by  no 
means  rare  in  the  later  periods  of  the  malady,  incoherence 
of  the  delusions,  the  use  of  odd  expressions  and  silly  puns, 
and  influence  on  will.  But,  on  the  other  hand,  exactly  the 
peculiarities  of  the  course  quoted,  as  the  rarity  and  the 
slightness  of  the  disorders  mentioned,  might  be  an  indication 
that  we  have  here  to  do  with  a  peculiar  morbid  process 
different  from  dementia  pra^cox. 

In  the  meantime  it  must  remain  doubtful  whether  the 
boundary  line  indicated  here  is  sharp  and  whether  it  has 
been  drawn  at  the  right  place.  In  any  case  it  is  often  still 
very  difficult  at  present  to  decide  in  the  beginning  of  the 
disease  whether  it  is  a  case  of  dementia  pra^cox  or  of  para- 
phrenia systematica.  The  evidence  for  the  latter  consists 
above  everything  in  the  very  late  appearance  of  distinct 
hallucinations  in  spite  of  a  delusion  of  persecution  which 
has  existed  already  for  many  years,  further  in  detailed 
mental  elaboration  of  the  delusions,  liveliness  and  passionate- 
ness  of  emotional  reaction,  absence  of  independent  disorders 
of  volition,  preservation  of  sense  and  of  reasonableness  in 
behaviour  and  action  with  delusions  that  are  already 
advanced. 

We  meet  with  almost  as  great  difficulties  as  in  the  delimi- 
tation from  dementia  pr^ecox  in  the  attempt  to  draw  the  line 
of  separation  in  the  direction  of  paranoia.  As  this  task 
cannot  be  begun  without  first  settling  more  exactly  the  con- 
ception of  paranoia,  which  is  still  fluctuating  inside  the  widest 
limits,  we  shall  be  obliged  to  postpone  till  then  the  discussion 
of  the  question.  A  separation  on  the  extended  territory  of 
the  psychoses  which  are  accompanied  by  progressive  delusions 
is,  as  shall  be  only  indicated  here,  perhaps  so  far  possible  that 
we  put  on  the  one  side  those  morbid  cases  in  which  we 
have  reason  to  assume  the  course  of  definite  morbid  processes, 
while  on  the  other  side  those  forms  would  have  to  be  placed, 
the  causes  of  which  we  regard  as  consisting  of  the  influence 
of  the  stimulus  of  life  on  morbidly  disposed  personalities. 
Whether  and  how  far   we   are  able  from  the  <riven    morbid 


PARAPHRENIA  361 

phenomena  to  draw  conclusions  a  posteriori  as  to  the  one  or 
other  history  of  origin  of  the  individual  case  will  be  elucidated 
later. 

Lastly,  there  has  still  to  be  considered  in  a  few  words  the 
delimitation  of  the  morbid  state  discussed  here  from  other 
paranoid  attacks.  From  the  alcoholic  forms  it  is  distinguished 
above  everything  by  its  insidious  development  and  its  con- 
tinuously progressive  course,  while  in  the  former  we  are 
brought  into  close  connection  with  an  acute,  or  at  least  a  sub- 
acute, form  of  mental  disorder  and  as  a  rule  with  the 
development  of  a  psychic  decline  distinctly  marked  after  a 
comparatively  short  time.  Moreover  in  the  alcoholic  attacks 
hallucinations  are  in  the  foreground  of  the  clinical  picture 
from  the  beginning;  in  paraphrenia  they  only  appear  after 
years.  Later  also  they  play  in  alcoholic  attacks  an  essentially 
larger  part ;  the  morbid  interpretations,  suppositions,  fore- 
bodings, on  the  other  hand,  wholly  disappear.  The  condition 
of  the  mood  is  in  drinkers  more  cheerful  or  indifferent,  much 
less  irritable  and  strained,  than  in  the  patients  discussed  here  ; 
the  phenomena  of  psychic  weakness,  senselessness  of  the 
delusions,  disconnectedness  in  conversation,  emotional  dul- 
ness,  docility,  appear  in  the  latter  much  more  rapidly  and 
more  markedly. 

In  syphilis  paranoid  attacks  also  usually  assume  striking 
forms  considerably  sooner  than  in  paraphrenia  ;  also  in  them 
likewise  hallucinations  as  a  rule  dominate  the  morbid  picture 
already  from  the  beginning.  The  delusions  are  far  more  dis- 
connected, not  so  systematized  ;  mood  is  much  more  changing 
and  inclined  to  sudden  explosive  outbursts ;  the  patients  are 
more  accessible,  more  easily  influenced.  Their  state  is  often 
subjected  to  abrupt  fluctuations,  in  contrast  to  the  obdurate 
stubbornness  with  which  in  paraphrenia  all  the  morbid 
phenomena  are  continuously  developing.  The  symptoms  of 
psychic  weakness  in  the  syphilitic  forms  become  much  sooner 
noticeable,  even  if  the  delusions  do  not  disappear.  Added  to 
that  there  are  above  everything  the  manifold  bodily  disorders 
caused  by  nerve  syphilis  and  the  demonstration  of  the 
Wassermann  reaction  in  the  blood. 

If  we  now  consider  the  presenile  delusion  of  injury,  which 
as  yet  is  still,  it  is  true,  very  inaccurately  delimited,  there 
must  specially  be  called  to  mind  the  indefinite  and  indistinct 
character  of  the  delusions,  which  is  peculiar  to  that  form  of 
disease.  The  delusions  are  not  mentally  elaborated  ;  they 
remain  suppositions  and  fears  engendered  afresh  at  the 
moment  and  often  changing  ;  they  come  and  go,  and  can  be 
displaced    by    persuasion,  being    quite    different    from    the 


302  DEMENTIA    PR/ECOX 

delusions  in  paraphrenia,  which  slowly  take  shape  but  then 
persist  with  great  stability  and  become  greater  in  extent.  It 
must,  however,  not  be  denied  that  in  the  earh'  prodromal 
periods  of  the  disease  this  distinguishing  mark  may  in  certain 
circumstances  be  absent. 

The  Treatment  of  the  disease  has  naturally  only  very 
small  scope.  As  the  patients  usually  suffer  very  much  in 
seclusion,  which  embitters  them  and  furnishes  fresh  nourish- 
ment for  their  delusions,  the  attempt  will  be  made,  as  far  as 
possible,  to  arrange  that  they  should  be  cared  for  in  freer 
circumstances,  possibly  in  a  family  or  in  the  country.  But 
unfortunately  the  disease  frequently  leads  to  actions  which 
make  institutional  care  indispensable.  In  these  circumstances 
one  will  endeavour  within  the  limits  of  necessary  supervision 
to  give  the  patients  as  much  freedom  as  their  state  will 
allow,  in  order  to  counteract  the  withdrawal  and  shutting  up 
of  themselves,  to  which  they  are  so  much  inclined.  One  will 
specially  try  to  give  them  opportunity  for  occupation  ;  it  is 
also  advisable,  as  far  as  possible,  to  promote  the  intercourse 
of  the  patients  with  the  outside  world  by  letters  or  personally, 
as  far  as  it  is  wished  by  them.  In  personal  treatment  great 
patience,  composure  and  foresight  are  necessary.  From  time 
to  time  it  may  be  expedient  to  avoid  all  contact  with  the 
irritated  patients.  Necessary  interference  (as  in  bathing, 
cleaning  of  the  neglected  room)  must  be  carried  out  with  the 
greatest  forbearance  but  with  firmness. 

Paraphrenia  Expansiva. 

Of  the  smaller  groups  of  diseases,  to  the  discussion  of 
which  we  now  have  to  turn,  the  expansive  form  of  paraphrenia 
is  characterized  by  the  development  o^ exuberant  viegalovmnia 
with  predominantly  exalted  mood  and  slight  excitement.  The 
disease  begins  as  a  rule  gradually,  but  also  sometimes 
subacutely.  Occasionally  a  period  of  anxiety  and  depression 
appears  to  precede  ;  an  elderly  unmarried  woman  believed 
that  she  was  pregnant,  and  put  on  very  thin  skirts  in  order  to 
conceal  her  state.  The  substance  of  the  megalomania  was  in 
half  of  my  cases  erotic;  it  concerned  exclusively  female 
patients.  The  patient  notices  that  a  gentleman  looks  at  her 
in  such  a  peculiar  way,  smiles,  makes  signs  to  her,  follows 
her,  waits  for  her  at  the  window.  On  the  street  remarks  are 
let  fall  about  it ;  highly  placed  persons  are  interested  in  the 
affair  ;  the  Virgin  Mary  gives  a  sign.  Everyone  knows 
about  it ;  the  affair  is  the  talk  of  the  town.     Ladies  in  grand 


PARAPHRENIA  303 

carriages  drive  past ;  the  military  march  through  the  streets  ; 
automobiles  come  ;  princesses  turn  to  look  at  the  patient ; 
the  Court  interferes.  The  advertisements  in  the  newspapers, 
the  pictures  and  articles,  indeed  even  the  speeches  in 
Parliament  contain  allusions.  A  secret  engagement  with  the 
"  spiritual  bridegroom "  takes  place,  of  which  the  patient 
learns  from  indications  in  the  street ;  she  is  greeted  with 
great  reverence.  It  becomes  clear  to  her  therefore,  that  there 
must  be  some  special  circumstance  connected  with  her  lover ; 
he  is  an  officer  high  up  in  the  service,  a  prince,  indeed  the 
King  himself,  or  even  the  Pope.  A  patient  wished  to  marry 
two  kings  at  the  same  time;  another  asserted  that  she  had 
been  made  pregnant  by  means  of  a  glass  of  beer  by  the  King 
of  Spain  who  shortly  before  had  actually  been  in  Munich. 

In  a  second  series  of  cases  religious  ideas  of  exaltation  are 
in  the  foreground.  The  patients  notice  that  people  speak  of 
them  as  of  saints;  the  clergyman  declares  them  from  the 
pulpit  to  be  such  ;  the  monstrance  bows  ;  they  have  at  times 
a  halo  round  their  head.  They  receive  inspiration  and  re- 
velations from  God,  possess  the  gift  of  prophecy,  associate 
with  Christ,  are  without  sin,  are  mediator  between  God  and 
mankind,  are  the  instrument  and  daughter  of  God,  can  work 
miracles;  they  have  received  special  grace,  must  co-operate 
in  the  redemption  of  the  world,  in  the  "  final  catastrophe." 
A  female  patient  called  herself  heaven's  bride,  expected  the 
angel-bridegroom  ;  she  declared  that  she  would  be  a  priest, 
indeed  that  she  was  the  third  person  of  the  Godhead.  Another 
asserted  that  for  seven  and  a  half  years  she  had  been  preg- 
nant by  the  Holy  Ghost ;  but  God  had  declared  that  He  did 
not  wish  to  come  into  the  world  in  the  institution ;  as  soon 
as  she  got  out  it  would  immediately  happen.  A  third  stated 
that  people  could  by  a  keen  gaze  pray  diseases  and  sins  on 
to  her;  the  latter  would  then  be  prayed  off  and  so  mankind 
redeemed,  while  she  would  get  rid  of  the  former  by  sleeping 
or  by  diarrhoea  with  flatulence  and  pains ;  in  this  way  man- 
kind would  once  more  be  healthy. 

Along  with  this  all  kinds  of  other  exalted  ideas  frequently 
appear.  Above  everything  the  patients  lay  claim  to  a  great 
deal  of  money.  Because  they  redeem  poor  souls  by  prayer, 
millions  have  been  collected  for  them,  which  have  been 
promised  to  them  ;  they  are  to  get  a  house  as  well,  the 
neighbouring  house  belongs  to  them.  They  are  enormously 
rich  ;  there  must  be  money  there.  "  A  queen  without  money, 
there  is  no  such  thing,"  said  a  female  patient,  who  considered 
herself  the  wife  of  King  Ludwig.  Other  patients  remain 
permanently  young,  doubt  whether  their  parents  were  the  real 


304  DEMENTIA    PR/ECOX 

ones,  are  of  high  descent,  acquire  great  titles ;  they  are 
rulers  of  the  world,  man  and  woman  at  the  same  time, 
royalties,  the  fate  of  the  world  ;  their  knowledge  is  great  and 
beyond  all  price,  fills  the  whole  world  ;  what  they  say  comes 
to  pass.  A  female  patient  had  inspirations  and  therefore 
knew  many  things  from  God  without  anything  being  said  to 
her,  for  example,  the  wishes  of  her  master  and  mistress  ;  in 
this  she  almost  never  made  a  mistake.  Another  foretold  the 
death  of  the  Empress  of  Austria,  wars,  the  appearance  of 
cholera,  the  birth  of  princes  in  Russia  and  in  Italy;  she  was 
therefore  asked  for  advice  by  many  people.  King  Ludwig 
was  called  back  to  life  by  prayer,  is  imprisoned  in  a  castle ; 
a  female  patient  led  him  to  God  and  redeemed  him. 

Hallucinations  almost  always  appear  fairly  .soon.  The 
patients  have  numerous  visions,  for  the  most  part  probably 
more  dream-like,  see  the  picture  on  the  high  altar  trans- 
formed, the  Holy  Trinity,  a  man  with  a  crocodile  head 
fighting  with  Saint  Michael,  Christ  on  the  Cross,  the  Child 
Jesus,  the  Virgin  Mary  on  a  tree,  a  monstrance  floating  in 
the  air,  a  king's  crown  with  Alpine  roses  and  swans  in  the 
sky,  erotic  proceedings  ;  in  the  water  of  the  fountain  figures 
appear ;  the  light  breaks  out  into  flame  as  soon  as  they  set 
foot  in  the  church.  At  night  the  King  comes;  they  speak 
with  him,  are  asked  if  they  would  like  to  marry  the  Emperor, 
the  King  or  His  Royal  Highness.  Heav-enly  voices  ring 
out ;  people  call  them  saints ;  the  Pope  speaks  to  them  ; 
God,  the  Holy  Sacrament,  the  Holy  Ghost,  give  them  con- 
tinually an  answer  to  the  question  what  they  should  do  ;  it  is 
said  low,  only  perceptible  to  themselves:  "  My  dear  child,  do 
what  I  tell  you ;  you  will  be  blessed."  The  neighbours 
whisper  secretly,  "  Saint  Anna,"  "  Here  comes  the  Saint," 
the  affairs  of  the  patients  are  talked  about ;  they  hear  every- 
thing that  is  said  in  the  house.  A  female  patient  carried  on 
"conversations  in  thought"  with  her  supposed  bridegroom; 
''  What  he  said  I  knew,  and  vice  versa."  Another  heard 
dogs,  birds,  cattle,  horses ;  then  also  flies  and  pictures 
speak  :  they  gave  answer.  The  dogs  were  employed  by  the 
police  to  watch  everything  and  to  bark  it  out ;  voices  came 
also  from  the  clouds.  Sometimes  it  comes,  as  already 
indicated,  to  inward  dialogues ;  to  thoughts  there  follow 
answers. 

From  the  description  of  herself  which  a  female  patient 
drafted  of  her  visionary  experiences  I  take  the  following 
fragments: — 

"So  it  came  about  that  Satan  left  me  no  peace  by  night  and  I  began 
thestruggle  with  him  afresh.  .  .  It  was  a  hard  struggle.    But  the  luminous 


PARAPHRENIA  305 

cross  of  my  Saviour  and  all  the  crosses  of  my  suflferings  (which  also 
signify  the  sufferings  of  the  world)  killed  him,  for  I  stabbed  his  heart 
with  all  invisible  cross-swords.  There  he  lay  dead,  the  dragon,  the 
beast,  the  monster.  But  I  took  my  stand  with  my  last  cross  held  high 
in  my  right  hand  on  his  paunch  belly  and  cried  three  times  with  a  loud 
voice:  'O  death,  where  is  thy  sting?  O  hell,  where  is  thy  victory?' 
And  when  the  serpent  heard  these  things,  it  came  slowly  and  sadly 
creeping,  for  it  had  no  more  strength  ;  it  had  lent  it  to  Satan,  that  he 
might  conquer  me,  and  when  I  saw  it  I  pierced  its  head  with  my  last 
cross-sword,  and  it  also  did  not  move  again.  Morning  had  long  since 
dawned.  The  birds  brought  their  songs  to  our  love.  .  .  Easter  !  'Tell  me, 
my  father,  why  is  it  Easter  for  me  to-day?'  '  My  child,  my  dear,  good 
child,  this  night  my  resurrection  took  place,  this  night  I  took  over  the 
kingdom  of  my  father.  .  .'  Then  came  the  night,  a  peaceful  glorious 
night.  But  it  was  not  to  last  long,  my  untroubled  happiness,  for  he  who 
before  was  the  embodiment  of  Satan,  who  was  then  happy  to  be  set  free 
and  called  himself  my  bridegroom,  he  came  spiritually  to  me,  in  order  to 
take  possession  of  the  bride,  but  what  did  he  take  ?  Not  the  spirit,  as  I 
hoped,  no,  my  pure  body  ;  he  looked  at  me  with  a  fearful  lascivious 
grimace  and  said,  '  Now  you  are  mine,  wholly  mine "...  But  the  old 
God  laughed  craftily  and  sang  out  of  Wagner's  Walkiire  ;  Blessing, 
laughing  love,  the  bond  of  Siegmund  and  Sieglinde.  Ha,  even  God 
helps  me  no  longer  ;  even  a  God  is  turned  into  a  swine.  ,  .  If  in  the  end 
now  God  Himself  wanted  to  flirt  with  you  !  Ha,  it  drives  one  to 
desperation,  to  insanity  ;  but  I  tell  you,  old  God,  that  I  whistle  at  you 
and  your  help,  and  at  your  love  too,  if  it  is  that  kind.  .  .  Touch  me  again, 
you  abominable  creature,  and  look  I  shall  put  this  six-barrelled  revolver 
in  my  mouth  and  discharge  it,  and  I  shall  lie  before  you  with  a  broken 
skull,  a  corpse,  then  go  on  playing  with  me  if  you  want.  .  .  ." 

Religious  and  erotic  trains  of  thought  are  here  spun  out 
in  high-sounding  form  to  visionary  pictures  which  were 
described  by  the  patient  partly  as  real  events,  partly  as 
inventions. 

Ideas  of  Persecution. — Hand  in  hand  with  the  megalo- 
mania there  are  invariably  ideas  of  persecution,  which, 
however,  in  the  whole  clinical  picture  do  not  acquire  a 
dominating  position  as  in  the  previous  form.  The  patients 
have  to  pass  through  trials,  are  to  be  oppressed  ;  danger  is 
threatening.  They  are  being  badly  treated,  being  laughed 
at ;  people  spit  in  front  of  them,  clear  their  throat,  blow  their  • 
noses,  threaten  them  with  their  fist,  knock  up  against  them 
on  the  street  with  packages,  pour  out  water,  knock  at  the 
doors,  let  the  water  run ;  everyone  is  in  the  plot.  The 
money  that  should  come  to  the  patients  is  withheld  from 
them ;  their  letters  are  suppressed,  their  things  are  stolen. 
They  are  being  poisoned,  magnetized ;  their  thoughts  are 
deciphered  by  the  physicians  by  means  of  apparatus. 
People  lie  in  wait  for  them,  wish  to  abuse  them  sexually, 
their  husbands  wish  to  get  rid  of  them  in  order  to  be  able  to 
enter  undisturbed  into  improper  relations  ;  dreams  give  cause 

U 


306  DEMENTIA   PR/ECOX 

for  jealousy.  Rivals  appear,  force  the  loved  one  to  marriage 
and  to  suicide.  In  the  newspapers  there  are  spiteful 
allusions  ;  wounded  men  and  hearses  come  in  sight ;  acquaint- 
ances die  ;  it  is  as  in  war. 

Here  also  hallucinations  may  play  a  part.  The  dogs 
bark  in  such  a  peculiar  way ;  allusions  are  made  to  cases  of 
theft ;  abusive  words,  slanders  are  called  out ;  someone  is 
calling  for  help ;  at  night  Satan  appears.  A  female  patient 
was  very  much  troubled  by  abuse  and  cries  of  the  "  Empress 
of  Pekin."  Occasionally  dysesthesias  due  to  strange 
influence  are  reported ;  a  female  patient  complained  that  a 
male  teacher  had  "  brought  apparitions  on  "  her. 

Pseudo-memories- — During  this  development  perception, 
orientation,  memory  and  retention  are  not"  essentially  dis- 
ordered in  the  patients,  still  pseudo-memories  occur  not 
infrequently.  The  prophecies  quoted  above  depend  on 
them.  Many  patients  state  that  they  had  already  known 
beforehand  that  they  would  come  into  the  institution,  also 
how  things  looked  there ;  they  greet  fellow-patients  as  old 
acquaintances.  A  female  patient  after  many  years  re- 
membered, as  she  thought,  a  meeting  with  King  Ludwig  ;  he 
treated  her  to  beer  and  proposed  to  her  that  she  should  sleep 
with  him  at  night.  When  she  told  her  father  about  it,  he 
laughed  and  said,  "  That  has  been  King  Ludwig  ;  you  will 
get  a  large  sum  of  money  yet."  Another  female  patient  saw 
a  paper  on  which  the  title  of  countess  was  granted  to  her. 
The  people  in  the  neighbourhood  are  often  taken  for  other 
people  in  a  delusional  way ;  they  are  princes  and  nobles  ;  a 
female  patient  for  many  years  called  the  physician  "  Little 
uncle  of  Nassau,"  even  after  an  absence  of  some  years ; 
another  woman  called  a  female  fellow-patient  "  her  little 
Ludwig."  Insight  into  the  disease  does  not  exist.  The 
patients  indeed  occasionally,  on  remonstrances  being  made, 
retract  some  of  the  delusions  to  which  they  have  given 
utterance,  but  immediately  afterwards  come  with  similar 
ideas  again.  A  female  patient,  who  discovered  in  the 
newspapers  the  most  nonsensical  allusions  to  her  affairs, 
spoke  of  her  "  newspaper  delusion,"  but  at  the  same  time 
continued  her  interpretations  unswervingly. 

Mood  is  self-conscious,  cheerful,  often  unrestrained  and 
irresponsible.  The  patients  are  inclined  to  jokes  and 
witticisms,  or  radiant  and  beaming  with  happiness.  There 
are  interposed  times  in  which  they  are  irritable,  high-flown, 
presuming  or  distrustful,  repellent.  In  their  conduct  they 
appear  as  a  rule  reasonable,  accessible,  pleasant,  but  easily 
fall  into  violent  excitement  if  people  occupy  themselves  for 


PARAPHRENIA  307 

a  considerable  time  with  them,  fall  into  a  preaching  tone, 
let  loose  an  enormous  torrent  of  words,  declaim,  prophesy, 
abuse,  threaten  to  make  a  whole  regiment  march  up,  give 
utterance  to  frightful  curses. 

The  Activities  of  the  patients  are  often  under  the 
domination  of  their  delusion.  They  try  to  approach  the 
object  of  their  love,  write  letters,  answer  advertisements  in 
newspapers,  make  preparations  for  marriage.  A  woman 
sent  the  most  high-flown  love-letters  to  her  husband's 
superior,  and  indeed  to  the  care  of  his  wife,  as  presumably 
she  was  directed  to  do  in  the  newspaper.  Another  female 
patient  for  years  remained  an  hour  and  a  half  every  day 
sitting  at  her  window,  because  she  thought  that  otherwise 
something  might  happen  to  her  beloved  who  lived  opposite 
and  had  no  forebodings ;  she  wrote  to  him  as  his  wife  and 
declared  to  her  own  husband  that  she  wanted  to  be  divorced 
from  him.  A  third  betook  herself  with  a  loaded  revolver  to 
a  married  physician,  with  whom  she  thought  she  lived  in 
spiritual  marriage,  and  threatened  to  shoot  him  and  herself. 
Other  patients  try  to  come  into  possession  of  money  that 
has  been  withheld ;  a  woman  tried  to  force  her  way  into 
the  Royal  Palace  and  cried  aloud  from  the  window  that 
she  would  stab  the  sovereign  because  he  did  not  pay  to 
her  the  sums  of  money  due  for  the  salvation  of 
souls.  Another  female  patient  went  to  Vienna  to  pre- 
vent by  her  prayers  the  plague  from  spreading  there ; 
a  patient  suddenly  ran  to  the  altar  during  service  and 
began  to  preach. 

Apart  from  such  derailments  and  the  more  transitory, 
though  often  very  violent  states  of  excitement,  the  patients 
may  appear  quite  inconspicuous  and  occupy  themselves 
reasonably.  Often,  however,  they  display  a  somewhat 
affected,  pompous,  unctuous  behaviour.  Many  patients 
compose  comprehensive,  bombastic,  and  turgid  documents ; 
a  female  patient  wrote  in  one  of  herself,  "  Myself,  us — the 
most  holy  Majesty  of  God  !  Sovereign  and  ruler  of  heaven 
and  of  earth !  Lord  and  Saviour-Imperator-Redemptor — 
of  all  princely  families — in  spite  of  my  tender  youth.   .  .  ." 

In  the  Further  Course  the  morbid  picture  as  a  rule 
only  changes  slowly,  as  far  as  I  can  judge  from  the  few  cases, 
which  were  observed  for  longer  than  a  decade.  The  patients 
remain  in  general  reasonable  and  clear,  but  adhere  firmly  to 
their  delusions,  which  perhaps  become  somewhat  more 
nonsensical  and  more  disconnected.  They  are  loquacious, 
verbose,  distractible,  at  the  same  time  lively,  accessible,  and 
docile;    they   exhibit  a  changing,  predominantly   confident 


308  DEMENTIA   PRECOX 

and  exalted  mood,  do  not  cause  any  special  difficulties  in 
medical  treatment.  Apart  from  great  lack  of  judgment, 
a  certain  incoherence,  superficiality  of  emotions,  and  weak- 
ness of  volition,  no  profound  dementia  appears  to  set  in, 
at  least  no  disintegration  of  psychic  personality. 

It  is  noteworthy  that  the  patients  whom  I  have  described 
were  almost  all  women.  The  commencement  of  the  malady 
was  in  three-quarters  of  the  cases  between  the  thirtieth  and 
fiftieth  year ;  one  case  began  first  at  sixty-four  years  of  age, 
without  there  being  any  possibility  of  senile  dementia.  No 
trace  could  be  found  of  specially  severe  hereditary  taint, 
and  just  as  little  of  external  causes  of  disease.  One  female 
patient  was  artistically  gifted,  another  had  always  been 
excited  ;  a  male  patient  was  reported  as  very  religious  and 
with  little  mental  endowment ;  in  several  other  cases  also 
there  had  probably  existed  for  a  long  time  conspicuous 
features  in  the  character. 

Delimitation. — Whether  the  morbid  states  brought 
together  here  as  an  experiment  really  constitute  a  clinical 
entity  is  doubtful.  On  the  other  hand  I  consider  it  almost 
certain  that  they  cannot  without  difficulty  be  placed  ip  one 
of  the  morbid  forms  otherwise  known  to  us.  From  dementia 
prcecox  they  are  distinguished  by  the  strikingly  slight  injury 
to  the  psychic  personality  even  after  a  duration  of  many 
years  in  spite  of  the  continued  existence  of  the  morbid 
phenomena,  further  by  the  absence  of  all  independent  voli- 
tional disorders  apart  from  the  affectation  which  is  perhaps 
connected  with  the  exalted  ideas  and  from  the  indications 
of  influence  on  will  which  appear  now  and  then.  Not  un- 
important is  perhaps  also  the  circumstance,  that  here  hallu- 
cinations of  hearing  and  above  everything  bodily  influences 
as  delusional  occurrences  go  completely  into  the  background 
behind  hallucinations  of  sight,  interpretations,  and  pseudo- 
memories.  This  circumstance  also  plays  a  part  for  the 
delimitation  from  systematized  paraphrenia.  But  to  that 
there  is  added  the  usually  more  rapid  development  of  the 
disease,  and  especially  the  mood  permanently  exalted  in 
spite  of  the  ideas  of  persecution  which  likewise  appear,  and 
the  accessible,  pleasant,  natural  behaviour.  Obviously  the 
patients  are  not  in  the  remotest  degree  so  tormented  as  the 
persecuted  persecutors;  the  continual  interference  in  their 
inner  life  which  by  those  patients  is  felt  as  so  extremely 
tormenting,  is  almost  entirely  absent  in  them. 

A  number  of  the  patients  described  here  I  considered  for 
a  long  time  to  be  manic.  Their  cheerful,  often  exultant 
mood  inclined  to  jokes,  and  their  prolix  loquacity,  as  also 


PARAPHRENIA  309 

their  outbreaks  of  excitement,  which  rapidly  become  worse 
by  external  stimulation,  make  this  interpretation  sometimes 
extraordinarily  probable.  However,  it  is  a  case  here  in  the 
first  place  of  only  single  attacks  which  moreover  may  without 
essential  change  continue  for  an  unlimited  time;' some  of 
my  observations  extend  over  twelve,  fourteen,  eighteen  years. 
Further,  after  a  considerable  time  the  gradual  development 
of  a  state  of  psychic  weakness  with  continuance  of  the 
delusion  is  unmistakable*.  Lastly,  the  excitement  is  often 
very  slight,  may  even  be  wholly  absent,  or  be  noticeable 
only  on  stimulation,  so  that  the  patients  display  nothing 
but  an  unreasonably  cheerful  and  confident  behaviour  with- 
out in  any  way  letting  themselves  be  disconcerted  by  their 
delusions.  As  I  suppose,  these  are  the  cases  which  caused 
Thalbitzer  to  bring  forward  his  "  manic  delusional  insanity  " 
which,  however,  may  include  still  more  cases  of  another 
kind. 

The  so  strongly  marked  predominance  of  the  female  sex 
might  moreover  point  to  distant  relationships  with  manic- 
depressive  insanity.  But  perhaps  the  thought  of  hysteric 
admixture  lies  still  nearer.  The  frequency  of  visionary 
experiences,  the  pompous,  self-conscious  behaviour,  the 
nimbleness  of  speech,  the  susceptibility  to  influence,  the 
tendency  to  make  oneself  conspicuous,  indeed  often  remind 
one  of  the  conduct  of  many  a  hysteric.  One  of  my  patients 
even  had  real  hysteric  seizures;  in  another  .the  disease 
apparently  began  in  the  form  of  a  "  magnetic  sleep "  with 
dreamy  religious  visions,  which  lasted  almost  without 
interruption  for  four  months.  Nevertheless,  in  view  of  the 
persistent  delusions  and  hallucinations,  of  the  slow  develop- 
ment of  the  malady  in  advanced  age,  and  of  the  evolution 
of  psychic  decline,  there  can  naturally  be  no  question  of  a 
real  hysteric  psychic  disorder,  quite  apart  from  the  fact  that 
phenomena  pointing  in  that  direction  come  under  observation 
only  in  a  minority  of  the  cases. 

Paraphrenia  Confabulans. 

The  next  form,  perhaps  related  to  the  previous  one, 
confabulating  paraphrenia,  which  certainly  includes  only  a 
small  number  of  cases,  is  distinguished  by  the  dominant 
role  which  pseudo-memories  play  in  it.  The  commencement 
appears  sometimes  to  be  a  change  in  the  conduct  of  the 
patients.  They  become  quiet,  reserved,  irritable,  withdraw 
themselves,  brood  a  great  deal,  and  then  gradually  come  out 


3IO  DEMENTIA   PRECOX 

with  a  narration  of  very  extraordinary  experiences  in  the 
sense  of  delusions  of  persecution  and  exaltation.  They  feel 
themselves  neglected  ;  they  are  persecuted,  robbed,  are  to 
be  poisoned.  Everywhere  there  are  suspicious  signs  ;  stones 
are  thrown,  the  windows  are  broken  ;  shots  are  fired.  People 
slander,  abuse  and  threaten  them,  cough  at  them,  put  out 
their  tongues  ;  anarchists  lie  in  wait  for  them  ;  a  cash-box 
with  bonds  in  it  was  stolen  ;  the  King  of  Prussia  will  have 
them  murdered  ;  they  are  being  sold  for  immoral  purposes, 
assaulted,  beheaded.  Many  patients  also  hear  voices,  low 
whispering  ;  someone  speaks  in  their  ear  and  says  what  they 
themselves  wished  to  say ;  people  are  whispering  secretly 
and  laughing. 

Sometimes  the  persecution  goes  back  into  childhood. 
Already  at  school  people  aimed  at  ruining  the  patient.  He 
was  mocked  by  his  relatives,  roughly  treated  by  his  teacher, 
tempted  to  masturbation,  was  to  be  "  ruined  by  bad  habits  "  ; 
his  mother  wanted  to  poison  him  with  an  apple.  Then  he 
fell  into  the  most  remarkable  dangers.  The  people,  with 
whom  he  came  in  contact,  were  murderers  and  procurers, 
used  abusive  language,  slaughtered  people,  buried  the  corpses 
or  packed  them  up  in  boxes  in  order  to  sink  them  in  water. 
It  was  announced  to  him  that  his  turn  would  now  also  come ; 
people  aimed  at  him,  were  going  to  slaughter  him  with  a 
long  knife,  to  blow  him  up  into  the  air  with  an  infernal 
machine  ;  five  years  ago  at  the  railway  station  he  saw  a  girl 
who  was  going  to  throw  a  bomb,  and  he  prevented  her  just 
in  time.  All  these  experiences  are  narrated  with  the  most 
exact  description  of  the  details  as  occurrences  that  have 
happened  quite  recently.  A  patient  reported  that  he  had 
dug  up  an  amputated  human  arm,  but  then  was  compelled 
by  his  neighbour  with  a  revolver  in  front  of  him  to  eternal 
silence ;  nevertheless  he  gave  information  and  an  inquiry 
was  really  made.  Another  went  into  a  brothel  in  order  to 
convince  himself  whether  cannibals  lived  there.  People  were 
aiming  at  his  life,  but  he  escaped,  though  later  human  flesh 
was  put  before  him  in  a  restaurant.  The  landlord  betrayed 
himself,  begged  to  be  allowed  to  shoot  him,  failed  however, 
and  shot  himself  on  that  account.  A  female  patient  was 
criminally  assaulted,  and,  because  she  knew  too  much,  was 
going  to  be  killed,  when  she  was  out  walking,  by  a  man 
who  already  had  many  murders  on  his  conscience,  and  spoke 
quite  openly  about  them  ;  finally,  however,  the  matter  was 
again  postponed. 

Megalomania- — The   confabulatory   springs   of  megalo- 
mania  flow   almost   still  more  abundantly.     The  patient  is 


PARAPHRENIA  311 

descended  from  a  royal  family,  is  the  illegitimate  son  of  a 
prince,  of  King  Ludwig  and  an  Italian  woman,  was  already 
in   childhood   abandoned   to   die  of  hunger.      Officers   and 
policemen  saluted    him  ;    he  was  called  the  wren  (German, 
hedge-king).     The  clergyman   made  obeisance  to  him  ;   his 
school  companions  called  him  Prince.     His  fellow-workmen 
were  the  King  of  Spain  and  the  Duke  of  Brunswick  ;  a  girl, 
the  daughter  of  the  Emperor  of  Austria,  said  to  him  that  he 
was  the  son  of  King  Ludwig  whom  he  resembled  to  such  an 
extent  that  his  real  mother  did  not  recognize  him,  and  at  a 
dance  wished  to  enter  into  connection  with  him.    The  police- 
men on  that  account  wore  their  beards  like  Ludwig  IL     He 
was   also  chosen   to  be  Emperor  but  felt  himself  still  too 
young   for   that.     At   the   railway   station    the    Emperor  of 
Austria  and  the  President  of  the  French  Republic  met  him  ; 
the  Grand  Duke  of  Baden  and  the  Emperor  came  disguised 
to  him  to  sound  him.     He  had  listened  to  important  political 
conversations  and  just  at  a  time  when  important  events  were 
happening.     When  he  was  only  sixteen  or  seventeen  years 
old,  it  was  imparted  to  him  that  he  would  get  a  house  in 
Berlin  and  inherit  the  estates  of  Prince  Schwarzenberg  ;  his 
mother  spoke  of  it.      At  the  post-office  a  letter  containing 
money  with  an  inheritance  amounting  to  a  million  was  shown 
to  him  and  it  was  said  that  the  sum  was  deposited  at  the 
bank.     As  a  child  he  was  taken  to  the  Royal  Palace  and  the 
room  where  he  was  born  was  shown  to  him  ;  later  the  King 
made   himself  known   to    him    as   his   father    by   look    and 
gesture.     The  patient  met  one  of  the  two  daughters  of  the 
King  ;  the  older  one  promised  to  marry  him. 

In  this  way  the  patients  bring  forward  with  the  most 
profound  conviction  an  enormous  number  of  extraordinary 
stories  absolutely  in  the  form  of  personal  experiences.  They 
can  describe  exactly  every  glance,  every  look  of  the  persons 
concerned  ;  they  report  every  word,  even  though  the  events 
are  referred  back  for  decades,  "  This  is  all  as  distinct  to  me 
as  if  I  saw  it  with  my  own  eyes  in  front  of  me,"  declared 
a  patient.  Sometimes  the  often  repeated  descriptions  fix 
themselves  in  the  patients'  minds  in  such  a  way  that  they 
are  repeated  almost  in  the  same  words.  But,  especially  in 
the  beginning,  it  is  sometimes  possible  by  questions  to  make 
the  patients  add  fresh  decorations,  and  they  themselves 
continually  produce  additions  which  meantime  have  occurred 
to  them.  The  patient,  who  had  dug  up  the  arm  of  the 
corpse,  reported  in  the  days  following  this  narration,  that 
his  neighbour  had  buried  something  that  smelt  of  corpses 
under  a  tree,  that  further  a  female  neighbour  had  spoken  of 


312  DEMENTIA   PRECOX 

shambles  in  the  cellar,  that  numerous  individuals  in  the 
village  disappeared,  the  patient's  mother  among  them,  that 
the  dogs  were  fed  with  human  flesh,  that  a  woman  of  the 
neighbourhood  threatened  him  with  a  revolver  and  announced 
that  it  would  be  his  turn  in  a  week  ;  lastly  that  one  of  his 
neighbours  followed  him  in  disguise  when  he  fled  into  the 
town. 

The  patients  usually  make  light  of  the  striking  circum- 
stance, that  their  remarkable  experiences  were  formerly  not 
taken  notice  of  by  themselves.  They  had  completely  for- 
gotten it,  have  not  thought  any  more  about  it,  made  no  use 
of  it,  only  later  everything  occurred  to  them  again.  A 
female  patient  said  that  she  had  first  thought  of  it  again 
when  a  whisper  like  a  prompter  had  reminded  her  of  every- 
thing ;  she  thought  that  her  mother,  who  had  foretold  much 
of  her  fortune  in  life,  had  then  taken  away  the  thoughts  of  it 
from  her  ;  "  She  understood  that." 

The  manner  in  which  the  patients  in  their  confabulatory 
narrations  draw  conclusions,  witnesses  to  the  easy  swiftness 
of  their  power  of  imagination.  A  patient  alleged  that  he  had 
heard  French  spoken,  therefore  the  President  of  the  French 
Republic  was  present ;  a  fellow-workman  spoke  of  Brunswick, 
therefore  he  was  the  Duke  of  Brunswick.  A  female  patient 
described  how  the  King  drew  little  round  arches  on  his  gar- 
ment with  his  finger ;  obviously  he  wished  by  that  to  signify 
the  rounded  arch  style  of  the  royal  palace  in  which  she  was 
born.  Another  said  she  had  heard  the  wife  of  a  guide  in  a 
picture-gallery  say,  "  Money  can  be  made  in  this  rag-shop"  ; 
from  this  it  was  clear  to  her  that  the  valuable  originals  of  the 
gallery  had  been  secretly  replaced  by  imitations. 

The  part  also  which  the  patients  ascribe  to  themselves  in 
their  pseudo-memories  is  very  remarkable.  Although  accord- 
ing to  their  account  it  was  said  to  them  in  so  many  words 
that  they  were  to  be  killed,  they  did  not  take  the  slightest 
measures  for  defence  or  flight,  continued  to  associate  for 
weeks  with  people  who  let  themselves  be  known  as  terrible 
robbers  who  also  committed  murder.  The  most  exciting 
information  about  their  royal  descent,  their  gigantic  inherit- 
ance, their  brilliant  prospects  of  marriage,  they  have  taken,  as 
they  allege,  with  the  greatest  equanimity  and  quickly  for- 
gotten again,  without  troubling  themselves  further  about  the 
matter,  till  it  by  chance  occurred  to  them  again.  Pointing 
out  all  these  impossibilities,  however,  usually  makes  little 
impression  on  the  patients  ;  they  admit,  perhaps  temporarily, 
that  it  was  "  all  nonsense,"  but  later  again  come  back  to  it. 

The   content  of  the  pseudo-memories   is   by  no   means 


PARAPHRENIA 


o^j 


always  limited  to  the  actual  delusions  of  persecution  and 
exaltation  ;  it  is  frequently  connected  also  with  more  remote 
personal  experiences  and  everyday  events.  It  occurred  to  a 
patient  that  he  had  formerly  seen  \\\s  fiancie,  who  he  thought 
was  very  rich,  and  also  her  father,  in  an  institution  ;  at  that 
time  touching  stories  were  told  him  about  the  sad  fortunes  of 
the  real  father  and  the  abominable  crimes  of  the  foster-father. 
A  female  patient  described- with  the  most  absolute  certainty 
a  great  many  occurrences  which  incriminated  her  husband's 
superior  in  the  most  serious  way  and  which  were  blindly 
believed  by  the  husband  himself  But  further,  she  reported 
most  extraordinary  experiences,  dating  about  twenty  years 
back,  with  Prince  Eulenberg,  with  Richard  Wagner,  and  with 
King  Ludwig,  in  such  a  clear,  lively,  detailed  way  that  she 
was  called  as  a  witness  in  a  lawsuit.  Another  narrated  that 
people  signified  to  her,  by  closing  their  eyes  and  nodding 
their  heads,  that  King  Ludwig  had  sat  by  the  water  and  had 
fallen  forward. 

Very  frequently  pseudo-memories  are  also  connected  with 
the  surroundings  of  the  moment.  To  the  patients  everything 
appears  familiar;  they  have  already  been  once  before  in  the 
rooms  of  the  institution  ;  the  house  and  everything,  that 
happens  to  them,  have  already  been  described  to  them 
previously  ;  it  is  a  hotel  in  which  they  lived  seven  to  eight 
years  ago  with  the  children  ;  they  remember  the  view,  the 
service  in  church  ;  it  gradually  comes  to  them  that  they  have 
seen  all  that  before.  The  physician  also  is  known  to  them. 
"  Don't  look  so  innocent,  as  if  you  had  nothing  to  do  with  it," 
said  a  female  patient.  The  nurses,  the  other  patients,  are  old 
acquaintances,  are  using  false  names.  "  Don't  impose  upon 
me,"  replied  a  female  patient  to  our  objections.  The  things 
which  others  are  wearing  belong  to  them ;  the  furniture 
comes  from  their  house.  The  same  persecutors  return  but  in 
changing  disguise.  A  female  patient  asserted  that  the  role 
of  her  husband  was  played  by  different  people,  that  he  was 
sometimes  smaller,  sometimes  bigger,  sometimes  stouter, 
sometimes  thinner.  The  children  also  have  been  exchanged, 
are  not  hers,  are  from  the  foundling  hospital.  At  a  visit  she 
did  not  acknowledge  her  husband,  but  tolerated  his  attentions. 

Besides  the  morbid  ideas  which  stand  in  relation  to  the 
pseudo-memories  there  are  as  a  rule  other  delusions  of  various 
kinds.  The  patient  is  to  be  deprived  of  his  rights,  is 
surrounded  by  detectives,  is  given  poison.  Visitors  are 
confined  in  the  cellar  ;  the  whole  house  was  cleared  out ;  a 
revolution  is  breaking  out  ;  Emperor  and  King  are  over- 
thrown ;   his  wife  has  murdered  the  children.     The  patient 


314  DEMENTIA   PR.ECOX 

believes  that  he  is  surrounded  by  murderers,  is  being  tortured. 
He  rs  related  to  Bismarck  and  the  Emperor  William,  receives 
a  message,  that  he  is  to  make  an  aristocratic  marriage.  His 
mother  is  not  dead,  has  inherited  a  house  from  Rothschild. 
Someone  tells  him  in  his  ear  that  he  is  Christ,  the  son  of  God, 
that  he  will  be  more  blessed  than  all  the  others.  He  has  the 
stigmata,  is  the  young  man  at  Nain  ;  the  ship  of  the  world 
was  about  to  perish  ;  then  one  has  come  to  save  it. 

The  Consciousness  of  the  patients  is  in  all  their 
nonsensical  delusions  permanently  untroubled.  They  are 
quiet,  perceive  without  difficulty,  give  clear  and  connected 
information,  behave  themselves  reasonably.  So  far  as  their 
delusion  does  not  come  into  question  they  are  usually 
perfectly  clear  even  about  their  surroundings  and  their 
position,  yet  the  occurrences  going  on  round  them  often 
appear  to  them  mysterious  and  incomprehensible.  "  I  could 
not  e.vplain  it  all  to  myself,  had  nothing  but  riddles  before 
me  and  would  have  soon  become  insane,"  declared  a  patient. 

Mood  in  spite  of  the  ideas  of  persecution  is  as  a  rule 
cheerful,  exalted,  "  quite  happy,"  yet  temporarily  anxious  or 
irritable.  The  patients  are  usually  very  accessible,  loquacious, 
verbose,  desultory,  with  a  tendency  sometimes  to  silly  plays 
on  words.  They  are  constantly  bringing  to  light  fresh  details 
of  their  delusional  recollections  with  great  vivacity  ;  they 
defend  their  ideas  with  vigour  and  ability,  let  themselves  also 
be  guided  in  their  activity  by  them.  They  go  to  the  police- 
office  to  get  information  there  about  their  affairs,  give 
information  to  the  public  prosecutor,  try  to  withdraw  their 
money  from  the  bank. 

The  Course  of  the  disease  seems  to  be  progressive.  For 
the  most  part  the  luxuriant  growth  of  pseudo-memories 
forms  only  a  comparatively  short  period  of  the  disease,  even 
though  the  delusional  inventions  are  retained  for  a  consider- 
able time,  repeated,  and  perhaps  still  somewhat  further 
adorned.  In  a  year's  time  they  may  have  completely  paled  ; 
the  patients  do  not  wish  to  hear  anything  more  about  them, 
do  not  know  anything  more  about  the  stories,  are  evasive ; 
*'  That  is  a  private  matter."  At  the  same  time  the  delusions 
become  more  nonsensical,  more  incoherent ;  mood  becomes 
irritable,  morose  or  indifferent,  so  that  no  doubt  exists  as  to 
the  development  of  a  psychic  decline.  Unfortunately  of  the 
cases  which  were  at  my  disposal  only  a  single  one  hitherto 
was  observed  longer  than  a  decade,  so  that  I  am  not  able  to 
make  any  more  precise  statements  about  the  last  fate  of 
these  patients. 

The  extremely  remarkable  morbid  state  described  here 


PARAPHRENIA  ^  315 

is  not  frequent ;  in  nearly  thirty-five  years  I  have  scarcely 
seen  more  than  a  dozen  marked  cases.  Both  sexes  appear 
to  be  equally  represented  ;  according  to  age  my  patients 
were  distributed  fairly  evenly  among  the  three  decades  from 
the  twentieth  to  the  fiftieth  year ;  they  were  therefore  on  the 
average  somewhat  younger  than  the  patients  discussed 
previously.  I  have  no  special  experiences  to  bring  forward 
in  regard  to  the  causes  of  the  disease,  except  that  of  several 
patients  it  was  stated  that  they  had  always  been  quiet  and 
introspective. 

Delimitation. — As  the  characterization  of  the  clinical 
picture  essentially  rests  on  a  single  clinical  symptom, 
certainly  very  striking,  but  one  which  in  less  marked  form 
occurs  also  in  other  forms  of  disease,  its  peculiar  place  must 
not  be  considered  as  on  sure  foundations.  Nitsche  has 
published  one  of  our  cases  in  agreement  with  myself  as 
chronic  mania.  Meanwhile,  after  more  exact  investigation 
of  a  considerable  number  of  paranoid  cases,  I  incline  to  the 
view  that  it  is  to  this  group  that  it  belongs.  Many  circum- 
stances, the  comparatively  early  commencement,  and  the 
psychic  involution,  certainly  as  a  rule  distinct  after  some 
years,  would  point  to  a  relationship  with  dementia  prcecox, 
especially  with  those  forms  which  have  been  called  idiopathic 
paranoia.  As  long,  however,  as  the  issues  of  the  group  here 
discussed  and  their  relations  to  dementia  prascox  are  not 
better  cleared  up  by  more  extended  series  of  observations,  I 
should  like  to  assign  to  it  a  place  by  itself  This  view  is  in 
any  case  supported  by  the  complete  absence  of  ideas  of 
bodily  influence  and  of  volitional  disorders,  unless  the 
occasional  making  of  faces  and  stiff  repellent  conduct  are  to 
be  regarded  as  such. 

Paraphrenia  Phantastica. 

A  last  group  of  cases  to  be  discussed  in  this  place,  like- 
wise not  very  comprehensive,  I  should  like  to  call  paraphrenia 
(dementia)  phantastica;  here  it  is  a  case  of  luxuriant  growth 
of  highly  extraordinary,  disconnected,  changing  delusions.  It  is 
covered  in  the  essentials  by  dementia  paranoides  formerly 
described  by  me  ;  as  meanwhile  this  term  has  been  in  general 
frequently  used  for  the  delusional  forms  of  dementia  praecox, 
I  consider  that  for  the  prevention  of  misunderstanding  it  is 
expedient  to  take  a  new  name.  The  disease  appears  often 
to  begin  with  ill-humour.  The  patient  becomes  enervated, 
spiritless,  depressed,  quiet,  anxious,  has  no  right  vitality, 
thinks  also,  perhaps,  of  suicide. 


3i6  DEMENTIA   PRyECOX 

Ideas  of  Persecution  then  gradually  come  to  the  surface. 
The  patient  notices  that  he  is  looked  at  in  a  certain  way, 
that  the  people  in  the  house  make  fun  of  him,  carry  on' 
spiteful  conversations,  seek  after  his  life,  listen  at  the  door, 
do  not  leave  him  any  peace ;  it  is  a  baiting  of  him.  He 
stands  by  the  hour  under  police  supervision,  is  denounced,  is 
made  answerable  for  everything,  is  to  be  castrated,  to  be 
punished  because  of  robbery  with  murder  and  theft ;  he  is  a 
subject  of  study,  and  must  do  penance  in  experiments ; 
people  wish  to  take  his  property  from  him.  His  letters  are 
not  dispatched  ;  in  the  newspapers  he  is  roundly  abused  ;  a 
flash  of  light  is  sent  through  the  room  by  electricity  ;  in  his 
absence  the  neighbours  force  their  way  into  his  house,  take 
away  clothes,  spoil  the  things  ;  they  are  a  gang  of  criminals. 
Officials  appear  with  falsified  certificates  and  under  false 
names;  his  wife  is  changed.  In  his  food  the  patient  finds 
saliva,  f?eces,  human  blood  ;  he  is  stupefied  with  chloroform 
and  sulphur ;  everything  is  drenched  with  sulphuric  acid,  is 
full  of  arsenic  and  phosphorus ;  his  bed  stinks,  contains 
serpents 

Hallucinations  of  Hearing  also  invariably  appear  now. 
The  patient  hears  whispering,  chirping,  wicked  slander,  whis- 
pering voices,  spirit  voices,  telephone  voices  from  the  ceiling, 
"  voices  in  public  and  when  people  meet  on  the  street." 
People  persecute  him  with  the  telephone  apparatus  ;  reproach 
him  with  his  faults  ("  wax  manufacturer  "  !),  call  to  him,  inform 
him  that  his  family  is  dead,  that  he  is  pardoned.  The  magis- 
trate and  the  police,  the  Emperor  and  princesses  speak ;  his 
sister  weeps  subterraneously.  Invisible  people  are  present  in 
the  room  and  speak ;  out  of  the  cushions  whispering  voices 
make  their  way  from  the  devil  and  his  light-bearers ;  his 
guardian  angel  speaks ;  Jesus  murmurs;  it  is  the  "  magic  of 
revelation " ;  the  spirit  of  hearing  is  sitting  in  his  ear. 
Animals  can  also  talk ;  "  I  have  spiritual  ears,  when  the  flies 
speak  to  me,"  declared  a  female  patient.  The  patient  carries 
on  conversations  with  the  voices,  converses  with  the  ministers 
in  Berlin,  telephones  with  God.  The  voices  accuse  him, 
praise  and  threaten  him,  dictate  to  him,  read  aloud  what  is  in 
his  letters  and  in  the  newspapers,  know  his  thoughts,  tell 
them  to  him  ;  a  compulsory  examination  of  his  thoughts  is 
taking  place.  They  also  make  remarks  about  what  he  does. 
"  Now  she  feels  it,"  is  said,  when  anything  is  painful  ;  "  Now 
he  is  speaking  French  so  that  he  may  not  be  understood"; 
'By  God,  she  says  everything;  everything  comes  up,"  a 
murderer  calls  out.  A  female  patient  heard  voices  which 
were  in  constant  contradiction  with  her  thoughts.     "  They 


PARAPHRENIA  317 

are  strange  spirits  which  speak  out  of  me,"  declared  a  patient. 
Another  had  a  feehng  as  if  he  repeated  what  he  heard  with 
the  breath  of  his  mouth ;  he  was  always  afraid  to  do  harm  by 
a  wrong  word.  A  third  distinguished  between  street-voices, 
conversation-voices  and  whispering  voices  ;  the  last  origin- 
ate from  people  "generated  inside,"  contained  in  his  interior; 
with  the  first  it  is  as  if  a  whole  street  would  appear  ;  "  The 
voices  are  let  loose,  meet  with  people,  are  established  firmly 
in  the  ears." 

Hallucinations  of  Sight  on  the  other  hand  usually  play 
only  a  small  part.  The  patients  see  the  light  from  the 
electric  current,  dark  shadows  which  go  out,  the  Saviour, 
the  heavenly  Father,  angels,  dust-insects  in  the  air,  bodies 
hovering  in  the  air,  figures,  which  change  their  form  and 
size  ;  people  are  changed  by  magic. 

*  Dysaesthesiae  and  Influence.  —  On  the  other  hand 
common  sensation  and  especially  the  delusion  of  personal 
influence,  which  is  connected  with  it,  takes  up  a  very  large 
space  in  the  morbid  picture.  The  patients  complain  of  pains 
and  dyscesthesia;  of  all  kinds  ;  they  are  tortured,  flogged, 
dishonoured  ;  they  feel  shooting  pains  in  leg,  head,  and 
breast,  burning  in  the  urethra,  formication  at  the  penis. 
People  give  them  colic  with  electrical  apparatus  ;  they  are 
pushed  about,  they  get  injections  in  the  skin,  are  stupefied. 
Their  testicles  are  electrified  ;  their  voice  is  altered  ;  their 
whole  body  is  changed  ;  their  thoughts,  their  memory,  are 
taken  by  spiritualistic  arts  and  roguery,  witchcraft  and  magic 
agencies,  by  invisible  persecutors  "  remaining  under  cover." 
A  patient  felt  pinching,  pricking,  pressing,  lightning  in  his 
brain  ;  his  heart  was  rubbed  down  with  a  curry-comb,  his 
bowpls  were  rhythmically  contracted  ;  another  thought  that 
he  had  instruments  in  his  body.  At  night  the  patient  is 
hypnotized,  dragged  away,  made  to  do  ugly  things  with 
females.  A  female  patient  had  the  feeling  as  if  someone 
were  always  about  her ;  at  night  someone  stood  behind  her 
and  confused  her  thoughts  ;  she  had  to  do  all  sorts  of 
indifferent  things,  had  to  cut  open  her  arteries,  was  abused 
sexually,  even  by  the  mouth.  "  People  have  such  an  influence 
on  me  that  it  is  terrible,"  complained  a  patient ;  "  I  cannot 
write  unless  they  wish  ;  they  have  an  influence  on  all  parts 
of  my  body." 

In  isolated  cases  these  sensations  and  ideas  acquire  quite 
prodigious  forms.  The  patient  was  made  sterile,  has  only 
a  few  small  stones  in  his  scrotum  ;  his  bones  are  being 
broken  ;  his  liver,  spleen,  lungs,  bowels,  the  root  of  his  penis, 
are  torn  out ;  his  marrow  is  sucked  out  by  devilish  instru- 


3i8  DEMENTIA    PR/ECOX 

merits,  his  sexual  parts  are  drunk  out,  his  breast-bone  is 
exchanged,  his  clavicle  is  cut  through  four  times  ;  his  head 
has  been  broken  in  pieces  nineteen  times  and  the  parts  torn 
out  have  been  replaced  by  new  ones.  His  body  is  being 
melted  down  ;  he  feels  the  circular  saw  in  his  head ;  his  body 
is  being  torn  asunder;  his  legs  are  being  taken  oft"  by  the 
railway  ;  his  arms  are  separated  by  a  great  distance  so  that 
he  feels  the  intervening  space  ;  his  eyes  stand  far  out  from 
his  head,  are  hanging  by  bloody  ct>rds  a  yard  long.  All 
machines  and  impulses  pull  at  him ;  his  organs  are  laid 
against  the  bulb  of  the  electric  light ;  the  mouth-harmonica 
is  sucked  fast  to  his  mouth  ;  he  feels  himself  harnessed  to  a 
kettle.  "  The  direct  mechanism  of  the  machine  is  the  point 
round  which  life,  so  to  speak,  the  organism  twines  itself  up  ; 
I  don't  know  how  that  is,  but  the  mechanism  pursues  me 
for  vengeance,"  said  a  patient.  The  voices  also  specially 
influenced  him.  "  This  talk  that  strikes  a  man  in  the  street, 
reduces  him  to  a  state  in  which  one  cannot  defend  himself; 
they  lie  in  wait  for  him,  drive  him  to  actions  of  violence," 
he  declared  ;  "  one  may  fall  down  because  of  it.  This  attacks 
men  in  their  innermost  parts,  excites  them  terribly,  comes 
like  lightning,  and  stirs  up  even  the  natural  and  actual 
circumstances  in  which  one  finds  oneself  at  the  moment." 
Another  patient  thought  that  he  was  being  attacked  by 
"  volitional  thoughts,"  invisible  strange  people  ;  when  he  read 
or  wrote,  wrong  letters  and  words  were  substituted.  A  third 
asserted  that  he  was  chained  to  the  whole  world. 

But  the  most  remarkable  thing  is  that  the  patient  feels 
and  sees  other  people  slip  into  his  body.  Individuals  dis- 
appear in  him,  lay  themselves  "  in  his  form  "  ;  a  whole  crowd 
of  people  can  be  dragged  along  by  him.  A  patient 
noticed  that  a  whole  motor-car  drove  into  him  ;  the  steering- 
wheel  stood  out  at  his  ears.  Freemasons  are  in  him  ;  his 
father  is  in  his  right  calf;  the  Emperor  Frederick  is  in  his 
body  in  order  to  be  saved.  His  whole  body  is  full  ;  people 
who  are  not  themselves,  wholly  torn  to  pieces  bodily,  head 
here,  spirit  there,  come  flying  out  of  the  air  ;  there  is  a  going 
in  and  out  like  a  dovecot.  The  patient  consists  of  thirteen 
individuals  ;  eight  females  are  inside  him.  "  F'ive  hundred 
females  were  in  me  and  outside  me,"  declared  a  patient. 
Another  said,  "  I  appear  to  myself  like  an  empty  room,  which 
is  constantly  inhabited  by  new  tenants.  What  use  is  it  that 
I  drive  them  out  ?     They,  are  so  shameless  and  come  again." 

Sometimes  the  troubles  are  of  markedly  sexual  nature.  A 
model  of  the  patient  has  been  made  ;  as  soon  as  the  sexual 
parts  of  it  are  touched,  he  is  stimulated  and  tempted  to  sin. 


PARAPHRENIA  319 

Aristocratic  persons  slip  in  and  out  of  his  penis  ;  a  princess 
sits  in  his  penis  ;  empresses  and  queens  beg  to  be  allowed  to 
play  with  it,  and  ask,  "  May  I  ?  May  I  ?  "  A  patient  asserted 
that  he  was  used  for  breeding  ;  people  were  bred  into  him, 
developed  in  him.  He  felt  that  he  was  being  copulated 
through  the  nose,  the  larynx,  through  wounds  into  which 
people  were  passing.  A  female  sexual  organ  developed 
on  his  eye,  while  the  rest  of  the  body  floated  in  the  air  in 
front  of  him  ;  also  in  a  wound  in  his  penis  a  girl  nine  years 
old  played  with  his  sexual  organs.  These  girls  spoke  through 
his  organs  without  his  wishing  it ;  he  was  accused  of  having 
done  wrong  to  them,  and  thought  that  was  perhaps  done  by 
other  men.  A  patient  felt  himself  pregnant,  called  himself 
Francisca,  wished  to  be  relieved  of  his  genitals  and  to  be 
placed  in  the  Maternity  Hospital,  and  he  wanted  to  become 
the  most  beautiful  woman  on  earth. 

Scarcely  less  incomprehensible  than  these  ideas  of  in- 
fluence and  of  being  possessed  are  the  other  delusions 
which  are  produced  by  the  patients  in  almost  inexhaustible 
abundance.  They  can  partly  be  classified  as  delusions  of 
exaltation  or  of  persecution  ;  but  partly  it  is  a  case  of  wholly 
senseless  and  aimless  playing  with  the  most  extraordinary 
and  sudden  ideas.  Their  relations  are  being  cut  to  pieces  ; 
their  father  has  throttled  his  two  sons  ;  in  the  storehouse 
200  people  are  daily  slaughtered.  In  the  house  there  is  a 
machine  for  beheading  people ;  many  have  alreddy  offered 
up  their  lives ;  poisons  and  soporifics  are  being  sold  to 
landlords  for  giving  to  their  guests.  An  international  enter- 
prise exists  for  "  getting  rid  of  people  "  by  means  of  lifts  in 
hotels,  which  unexpectedly  go  down  into  subterranean  vaults. 
There  a  sausage-machine  stands  for  the  many  slaughtered 
people ;  already  during  six  years  milliards  of  people  have 
been  daily  murdered  ;  whole  towns  are  empty ;  it  is  a 
devilish  crime.  Everyone  is  eating  human  flesh  ;  the  food 
contains  human  blood  and  female  genitals ;  from  bones  and 
brain  cheese  is  made  ;  Prussians  and  parsons  are  behind  it 
all ;  everything  happens  by  the  order  of  the  master  of  the 
lodge  for  penance.  Everywhere  there  are  electric  wires ; 
the  fellow  -  patients  are  procurers;  disguised  enemies  are 
there;  they  have  taken  the  complexion,  the  capacities,  speech 
from  other  people  by  magic  ;  the  Sovereign  has  shot  himself, 
is  a  robber  who  commits  murder ;  the  end  of  the  world, 
the  fulfilment  of  the  Revelation  is  at  hand.  The  patient  is 
by  a  bull  of  excommunication  enchanted  into  a  horse  for 
his  whole  life  long ;  he  has  insect  spirits  in  his  body  ;  he 
has  often  been  stabbed  and  shot ;    he  has  three  hearts,  is 


320  DEMENTIA   PR.ECOX 

now  without  heart  and  lungs,  is  already  dead,  cannot  think 
any  more,  has  female  genitals. 

On  the  other  hand  the  patient  is  descended  from  noble 
parents,  is  the  stolen  child  of  the  Queen-Dowager,  has  been 
taken  from  a  golden  cradle  to  a  shoemaker  and  his  wife,  is 
the  son  of  Prince  Charles,  Duke  of  Habsburg,  according  to 
rank  Emperor  of  Berlin,  President  of  the  Republic  of  Hesse. 
Other  patients  are,  he  who  is  to  come.  Emperor  and  God, 
first  and  last  man,  the  first  prince  from  the  beginning  of  the 
world,  a  supernatural  being,  a  fairy  prince.  Royal  Highness, 
Majesty  of  Heaven  and  of  Earth,  Regent  of  the  apes, 
Emperor  of  Austria,  Napoleon,  appointed  to  be  King  of 
Bavaria,  Emperor  of  the  world  and  owner  of  the  whole 
world.  ,  The  whole  of  Europe  belongs  to  the  patient ;  he 
has  ruled  over  town  and  country  from  birth.  A  patient 
declared  that  the  old  Emperor,  the  Emperor  Frederick  and 
the  present  Emperor  were  united  in  him  ;  inside  another 
patient  Prince  Charles  and  the  Emperor  Frederick  had  been 
since  he  was  five  years  old ;  "  Together  we  are  called 
Charles  F'rederick,"  he  said.  Women  are  the  Madonna  of 
Lourdes,  Grand  Duchess  by  birth,  the  most  highly-placed 
woman  on  earth,  stolen  from  Coburg,  the  second  Queen 
Luise  by  her  "high,  high,  high,  high  father,"  goddess  of 
hunting,  the  highest  and  noblest  that  exists.  Majesty  Clara, 
Regent  of  the  House,  capitalist  of  disease ;  they  will  give 
birth  at  Christmas  to  a  Child  Jesus,  want  to  marry  a  high 
officer  ;  a  female  patient  declared  that  she  had  many  children 
by  Saint  Theresa. 

By  the  grace  of  God  the  patient  has  become  infinitely 
rich,  will  receive  for  his  piece  of  ground  an  untold  price,  is 
getting  millions  of  money  and  jewels  from  the  Emperor  of 
Austria  and  from  an  American  railway  king,  demands  his 
milliards,  possesses  a  kingdom  of  millions,  thousands  of 
square  miles  in  Mars,  Neptune,  and  Venus,  wants  to  go  to 
his  palace,  has  inherited  everything  here,  gets  for  each  day 
100,000  marks  damages,  receives  cash  remittances  from  all 
quarters,  which  are  embezzled.  He  can  make  bread  from 
stones,  has  studied  the  original  language,  has  a  knowledge  of 
important  state  secrets  ;  he  is  to  marry  a  princess,  is  secretly 
married  to  six  majesties.  Prince  Bismarck  is  coming ;  the 
King  of  the  Netherlands  will  set  him  free  ;  a  prince  is  waiting 
in  the  next  room  ;  the  Emperor  Francis  Joseph  is  there,  who 
has  married  the  patient's  sister.  He  is  nourished  by  the 
earth  magnet,  fed  by  the  Holy  Ghost  who  tells  'him  every- 
thing, is  in  him,  draws  off  the  poison  ;  he  takes  copies  of  the 
most  beautiful  pictures  by  golden  wires  with  magnetic  print- 


PARAPHRENIA 


321 


ing  and  electricity ;  he  possesses  the  African  method  of  h'fe 
so  that  he  cannot  die,  has  grace,  is  in  the  service  of  the 
Godhead,  receives  revelations  from  the  spiritualists  about 
the  approach  of  the  end  of  the  world ;  words  of  God  flow 
from  his  mouth ;  God  lives  in  his  body. 

The  delineation  of  the   high-flown   exalted  ideas  leads 
sometimes  to  an  extraordinary  expenditure  of  superlatives 


^^^^^P^^    ^ 


Specimen  of  Writing  7.     Paraphrenia  phantastica.      x  f , 

in  which  the  patients  try  to  describe  their  immeasurable 
superiority  and  suffering.  An  idea  is  given  of  it  by  the 
following  extract  from  one  of  the  innumerable  documents 
endlessly  repeated  in  a  similar  way  with  which  a  female 
patient  furnished  us.  I  add  from  them  also  a  specimen 
of  writing  in  which  the  effort  is  made  in  its  large, 
pretentious  features  to  do  justice  to  the  highly  strained  self- 
consciousness. 

"  I  have  here  the  Highest  of  all,  the  most  Immeasurable  of  all,  the 
most  Sublime  of  all  the  most  Colossal  of  all  the  most  Boundless  of  all 


322  DEMENTIA   PRECOX 

the  most  Unlimited  of  all  the  most  Distinguished  of  all  only  Highest  of 
all  only  most  Immeasurable  of  all  only  most  Sublime  of  all  only  most 
Colossal  of  all  only  most  Unlimited  of  all  (so  on  for  six  folio  pages),  born 
the  being  possessing  the  most  Devoted  most  Loving  most  Passionate 
Embracing  all  Embracing  all  more  than  all  hottest  Hottest  of  all 
Reverence  Love  Thankfulness,  Devotions,  Passions,  Adorations,  Adora- 
tion. .  .  I  was,  am  and  remain  this,  a  most  Excellent  of  all  a  Greatest  of 
all  Unique  thing  of  immortality  in  the  most  Many-sided  involuted 
manner  kind  of  accomplishment  !  .  .  .  Have  been  almost  three  years  in 
the  most  terrible  way  the  victim  of  a  most  bestial  most  dreadful  band  of 
murderers  and  robbers,  by  which  I  was  slaughtered  to  the  most  dreadful 
cripple  with  the  pains  of  death  murdered  and  robbed  am  besides  was 
murdered  in  comparison  with  my  former  most  perfect  beauty  in  a  most 
dreadful  ugliness,  was  am  murdered  and  robbed  it  reaches  back  to  my 
birth  1  suffered  suffer  as  continuous  victim  of  all  bands  of  murderers  and 
robbers  on  the  earth  the  most  boundless  murders  murders  with  robbery 
murders  of  honour  I  was  am  remain  the  most  Excellent  of  all  most 
Versatile  most  Sublime  Best  most  Immortal  being  was  most  enormously 
rich  most  Magnificent  Monarch  of  Many  States.  .  .  ." 

The  capital  letters  should  be  noticed,  the  absence  of 
marks  of  punctuation,  the  anxiety  by  repetition,  by  using 
stronger  terms,  by  the  conjunction  of  past  and  present  to 
attain  to  the  greatest  possible  impressiveness,  lastly  in  the 
specimen  of  writing  the  singular  mannerism  of  writing  single 
letters  (here  the  m)  twice  in  different  ways. 

Pseudo-memories. — Frequently  the  delusions  clothe 
themselves  in  the  form  of  pseudo-memories.  The  patient 
had  from  the  beginning  a  foreboding  soul  ;  as  a  child  he  was 
stolen,  abused,  had  to  endure  great  struggles  ;  he  made 
journeys  to  China  and  to  the  North  Pole,  was  appointed 
King  of  Bavaria  in  the  Parliament  nine  years  ago.  He  was 
fished  up  from  the  River  Amazon,  rubbed  together  from 
saliva,  made  small  by  plaster  of  Paris  dressings,  hounded  for 
twenty-five  years  through  the  animal  kingdom.  People 
wanted  to  strangle  him,  behead  him,  poison  him,  throw  him 
from  the  tower,  kill  him  by  electricity.  He  was  Christ  and 
Paris,  Eve,  Moses,  Alexander  the  Great,  Cctsar,  Victoria, 
Mary  Stewart,  the  Maid  of  Orleans,  Eugenie,  Napoleon,  was 
killed  several  times,  pierced  by  fifty  bullets  and  thousands  of 
needles,  already  as  a  boy  poisoned  with  cantharides,  was  to 
have  been  misled  to  onanism  ;  he  created  the  first  j^eople, 
has  studied  medicine,  was  lecturer  at  a  university,  changed 
every  two  hundred  years  between  studying  and  ruling,  was 
to  direct  the  whole  world  in  seven  years.  He  has  eaten  a  bit 
of  the  archbishop,  carried  on  a  conversation  with  the  devil  of 
Zurich  ;  he  was  also  the  serpent  of  Paradise ;  he  is  always 
being  born  again,  has  lived  already  a  dozen  times,  has 
founded  the  town  of  Jerusalem,  has  deposed  all  dynasties, 
appointed  stadholders  instead,  spends  the  night  in  the  under- 


J 

^ 


PARAPHRENIA  323 

world,  fights  fearful  battles  day  after  day  with  the  enemies 
of  the  country.  He  was  professor  to  the  Queen  of  England, 
saw  there  a  machine  for  manufacturing  children,  worked 
along  with  the  Hereditary  Grand  Duke  as  joiner  and  stone- 
mason, was  in  1895  in  the  assembly  of  spirits,  was  also  the 
huntsman  who  shot  the  girl  in  Switzerland.  An  inward 
voice  tells  him  everything  that  is  going  to  happen.  The 
institution  has  already  been  built  ninety-seven  times  ;  the 
fathers  also  have  done  penance  here. 

Sometimes  delusions  of  this  kind  are  connected  with 
every  idea  aroused  by  chance ;  the  patient  has  himself 
experienced  every  event  in  history,  which  is  mentioned  in 
conversation ;  he  was  the  Emperor  William,  Bismarck, 
Napoleon  I.  and  HI.,  Alexander  III.,  all  in  one  person  ;  if  the 
conversation  is  about  cloth-mills,  he  declares  that  he  himself 
possesses  large  cloth-mills  in  all  the  towns  of  Germany;  he 
tells  the  physician  of  the  most  marvellous  operations  which 
he  has  carried  out  as  surgeon  ;  he  already  knows  all  the 
newly  admitted  patients,  as  he  knew  them  previously ;  he 
can  narrate  extraordinary  experiences  with  them.  A  patient 
discovered,  when  out  walking,  lions,  buried  cities,  gold  and 
silver  mines. 

All  kinds  of  other  confabulations,  which  do  not  bear  the 
form  of  personal  experiences  are  probably  nearly  related 
to  pseudo-memories.  A  female  patient  narrated  the  most 
nonsensical  stories  from  the  past  history  of  her  fellow- 
patients  ;  a  patient  asserted  that  Christ  had  been  crucified 
in  Augsburg ;  the  battle  of  Hermann  did  not  take  place 
in  the  Teutoburger  Forest  ;  Bismarck  was  still  alive. 
Another  related  that  Napoleon,  his  brother,  had  been 
beheaded  the  previous  winter  in  France.  Here  belong 
also  the  ideas  of  descent  which  frequently  come  to  the 
surface.  A  female  patient  thought  that  the  seed  of  wrecked 
human  beings  got  out  of  the  sea-water  into  sharks,  there 
become  "  rochus,"  and  then  again  human  beings ;  from  the 
union  of  women  and  animals  there  arise  half-men  ("Gromen"); 
she  spoke  of  "  seed-sisters  and  brothers,"  who  must  marry 
each  other.  Another  declared  that  her  mother  was  descended 
from  the  dove  of  Zacharias;  the  first  bride  of  Christ  was 
an  Indian  girl,  Lararuk  ;  she  herself  was  the  second,  and 
overshadowed  by  Him  she  became  the  mother  of  the  Christ- 
child  at  Munich.  Another  time  she  narrated  that  4000 
years  ago  Christ  had  married  Lucinda,  and  she  was  descended 
from  this  union ;  the  Gospel  was-  wrong ;  it  was  beneath 
the  dignity  of  a  God  to  let  Himself  be  begotten  and 
crucified.     Further  she  was  a  grand-daughter  of  Napoleon 


324  DEMENTIA    PRECOX 

who  married  her  grandmother  in  the  cathedral  at  Spires ; 
he  was  accompanied  everywhere  by  Christ.  The  heir  to 
the  throne  was  descended  from  a  peasant  wench,  his  wife 
from  a  bishop,  who  had  100,000  children. 

A  patient  elaborated  a  comprehensive  narrative  of 
historical  connections,  freely  invented,  in  which  he  declared 
all  royal  families  to  be  spurious,  all  statements  of  history  to 
be  falsified ;  he  had  made  many  investigations,  had  taken  a 
great  deal  from  American  newspapers,  and  he  possessed 
excellent  intellectual  powers.  Accordingly  the  patient  was 
descended  from  the  Duke  of  Reichsstadt  who  was  a  female 
and  the  daughter  of  the  real  Napoleon  and  of  the  daughter 
of  the  real  Frederick  II.;  the  former  was  a  chemist  in 
Baireuth  and  lived  to  be  130  years  old;  the  latter  was 
a  hermaphrodite  and  was  deposed.  William  I.  also  was  a 
hermaphrodite,  and  was  superseded  by  a  master  shoemaker  ; 
the  Emperor  Frederick's  real  name  was  Frederick  Geier 
(Vulture),  and  he  came  from  Niirnberg.  Ludwig  II.  con- 
sisted of  three  persons;  the  first  was  a  sodomite  who  com- 
mitted rape  and  murder  and  was  later  a  clergyman  in  the 
Allgau,  the  second  was  the  son  of  a  day-labourer,  the  brother 
of  Clara  Ziegler,  and  was  still  living  in  poor  circumstances; 
the  third  is  a  hermaphrodite  and  became  an  actor.  The 
Habsburgs  are  a  baker's  family  from  Eriangen  ;  the 
Hohenzollerns  are  derived  from  Hungarian  Jewish  circles, 
the  Russian  Emperor  from  the  Jesuit  family  of  the  Medici 
in  Baireuth.  The  patient  declared  that  he  himself  was 
the  last  scion  of  all  these  and  of  many  other  princely 
families. 

As  already  appears  from  the  foregoing  description,  it  is 
here  everywhere  a  case  not  of  connected,  mentally  elaborated 
circles  of  ideas,  but  of  variegated,  often-changing  sudden 
ideas  of  a  moment,  some  of  which  are  certainly  retained 
for  a  time,  but  which  mostly  are  replaced  by  ever  new 
and  just  as  transient  creations.  A  patient  at  repeated 
interviews  called  himself  Graf  Eberstein,  Monarch  on  the 
Prussian  throne.  Lord  of  the  Dead,  a  new  God  as  Prussian 
general.  Prince  William  in  uniform,  last  professor,  soldier, 
American  gentleman,  guardian  of  the  institutron,  double 
District  Medical  Officer. 

During  the  extraordinary  delusions  described  the  patients 
may  be  completely  sensible,  clear  and  reasonable  in  their 
behaviour,  yet  they  often  mistake  in  a  delusional  way  their 
surroundings  and  individuals  ;  they  are  in  their  kingdom,  in 
the  penitentiary,  in  the  devil's  den  of  murderers,  in  the  den 
of  rape,  murder,  whoredom  and  robbery  ;  they  see  round  them 


PARAPHRENIA  325 

acquaintances,  highly  placed  persons,  viragoes,  enemies  ;  the 
physician  is  Charlemagne.  Sometimes  the  patients  have 
a  certain  feeling  of  the  change  which  has  taken  place  in 
them,  but  no  clear  understanding  of  its  significance.  A  patient, 
who  was  usually  extremely  irritable  and  violent,  had  interven- 
ing periods  in  which  he  was  accessible  and  exaggeratedly 
grateful,  but  without  real  insight  into  the  disease ;  he 
thought  then  that  he  was  "  as  if  awakened  from  a  long  sleep," 
to  be  after  some  time  again  dominated  by  the  old  delusions. 

Mood  is  as  a  rule  somewhat  exalted  or  indifferent,  but 
sometimes  also  gloomy,  strained,  and  inclined  to  violence.  In 
conversations  of  any  length  the  patients  fall  into  a  certain 
excitement.  They  usually  bring  forward  their  delusions 
with  fluency  and  prolixity,  often  in  a  very  confused  and 
desultory  manner,  while  they  are  able  to  give  information 
about  remote  questions  clearly  and  to  the  point.  Their  con- 
duct is  frequently  somewhat  affected  ;  occasionally  grimacing 
is  observed.  Their  speech  is  usually  interspersed  with 
peculiar  turns  of  expression,  but  specially  neologisms.  A 
patient  spoke  of  the  "  alphathunderbook,"  the  compendium 
from  the  court  law  or  university  lexicon,  called  himself  the 
"  cyklesteraksander  and  brain  inventor";  Aksander  was  a 
Christ-brain,  Cyklester  a  penitential  body,  Rader  someone 
who  speaks  out  of  one  without  one  noticing  it.  A  female 
patient  declared  that  princes  had  as  dynasty  people  (suite), 
"feds,"  dukes,  "  fesochs,"  emperors  and  kings,  "fusaltos";  the 
world  was  a  "cultar,"  a  magnet,  which  forces  vegetation. 
Her  parents  drove  into  the  "  Erdall,"  were  merely  killed  ;  her 
ancestor  was  "  Doreal "  with  the  Emperor  of  Iceland,  which 
again  consisted  of  Rumenien,  Ostrumenien,  Jeromin  and 
Morasto ;  her  grandfather  went  with  Emperors  and  Kings 
into  the  Erdterail,  in  order  to  hold  Tyram  or  Tore.  Another 
female  patient  thought  that  she  had  been  dragged  in  as  a 
poodle  and  suction-pump.  Many  sentences  may  be  quite 
incomprehensible.  "  That  is  a  great  family  word,  that  will 
never  end,  without  war  and  deeds,"  declared  a  female  patient ; 
she  had  as  a  child  experienced  the  most  wonderful  things, 
the  virgin  icxx)  and  no  night;  "that  is  beautiful  and  pay- 
able." 

Silly  plays  on  words  also,  nonsensical  rhymes  and 
witticisms  are  not  infrequent.  A  female  patient  said  that  she 
was  Socrates,  should  do  "so  grad'es";  a  patient  connected 
"  Chamisso — Scham  is  so,"  "  Wahrheit — wahrer  Heid," 
"  Doktor — Dogg-Tor  "  ;  another  spoke  of  Leipzig  "  the  town 
of  the  sacred  masses  and  of  the  sacred  religions,  of  the  sacred 
legions."     A  third  thought  that  fractures  could  be  cured  by 


326  DEMENTIA    PRv^COX 

introducing  the  new  calender  and  abolishing  fractional 
arithmetic  ;  he  wanted  by  the  abolition  of  prostitution  to  turn 
"  Klagenfurt"  into  "  Ehrenfurt."  In  spite  of  such  occasional 
nonsensical  interpolations  the  patients  can  still  usually  make 
themselves  quite  intelligible,  especially  if  the  matter  in  hand 
has  not  to  do  with  their  delusions  ;  they  sometimes  write 
faultless  letters. 

An  example  of  the  peculiar  utterances  of  such  patients  is 
given  in  the  following  transcript : — 

"  You  will  probably  know  what  that  means  to  be  an  immortalized 
spirit,  although  I  am  only  a  simple  beer-brewer  and  had  to  go  through 
that  if  anyone  raises  himself  from  a  low  rank  to  the  nobility.  It  was 
certainly  from  birth  Count  Eberstein,  but  first  by  the  head-disease  and 
the  strained  memory  the  accession  has  resulted,  so  that  he  is  Frederick 
William  III.  from  then  onward  the  fourth,  which  therefore  has  direct 
relation  with  William  I.  and  Frederick  III.  That  means  the  immortalized 
and  that  means  that  he  is  not  it  now  for  the  rabble  ;  we  know  well  why 
the  pictures  and  flags  have  been  waved  to  the  right,  that  means  the  right 
one  will  come.  .  .  I  know  that  I  am  mad  ;  that  means  that  I  must  suffer 
by  head-disease  and  by  memory  voices,  but  then  it  is  also  possible  that  a 
common  fellow  comes  to  high  station  ;  that  will  mean  much,  if  one  is  to 
have  memory  for  the  general  staff  and  the  government.  .  .  You  have  not 
the  least  idea  how  much  goes  on  in  my  head  ;  I  often  think  it  must  burst. 
You  don't  know  at  all  what  happens  to  me  at  night ;  I  frequent  in  fact 
the  most  glorious  marble  halls  at  night  ;  then  I  am  many  miles  away. 
Last  night  I  had  20,000  marks  in  my  hands  ;  here  there  are  only  twenty 
and  ten  mark  pieces,  but  there  there  are  also  thirty  mark  pieces  ;  that  was 
not  in  dream,  but  by  day  ;  there  was  on  the  pieces  the  President  of  America 
from  Hamburg.  Indeed  you  don't  know  at  all  what  intercourse  I  have  at 
night,  the  expanding  pictures  ;  then  I  am  indeed  in  glorious,  wholly 
unknown  towns,  where  I  never  was  before,  or,  as  last  night,  in  glorious 
ships  on  the  sea.  In  this  world-globe,  which  I  frequent  at  night,  it  is 
quite  different  from  here  ;  it  is  perhaps  a  continent  behind  the  moon.  I 
am  far  away  outside,  though  I  am  in  the  asylum.  In  December,  January 
I  have  eaten  cherries  there,  when  here  in  winter-time  there  are  certainly 
none  at  all.  .  .  For  eighteen  and  a  half  months  already  I  have  been 
William  I.;  but  through  the  length  of  time  I  have  obtained  the  double 
order  of  the  crown  ;  at  that  time  I  was  already  as  much  as  the  most 
mighty  King  on  earth.  If  Jesus  Christ  had  been  let  go  free  and  not 
innocently  crucified,  perhaps  it  would  have  happened  to  him  as  to  me,  by 
the  head-disease  throughout  become  equal  with  his  father.  .  .  ." 

On  the  one  hand  the  mental  activity  of  the  patient 
appears  here  in  the  vivacity  of  the  descriptions,  on  the 
other  hand  there  is  occasional  derailment  into  quite  incom- 
prehensible turns  of  expression  and  trains  of  thought. 
Further,  the  fabulous  exalted  ideas  come  to  the  front  with 
wonderful  nocturnal  experiences  probably  pointing  to  pseudo- 
memories,  lastly,  there  is  the  morbid  feeling  which  shines 
through  and  which  is  brought  into  singular  relations  to  the 
exalted  ideas. 


PARAPHRENIA  327 

The  Course  of  the  morbid  form  described  here  is  pro- 
gressive. In  time  the  utterances  of  the  patients  usually 
become  i^radually  more  confused  and  more  disconnected. 
The  neologisms  and  queer  turns  of  expression  often  greatly 
prevail  ;  the  behaviour  also  often  becomes  peculiar.  The 
emotions  become  duller  with  rapid  explosive  outbursts  of 
violence  and  transient  states  of  excitement.  Many  patients 
remain  permanently  capable  of  M'ork  ;  others  are  limited  to 
long-winded  speeches  and  the  composition  of  comprehensive, 
scarcely  comprehensible  documents.  The  rapidity  with 
which  this  dementia  develops  appears  to  be  very  varying. 
Sometimes  it  is  already  distinctly  marked  at  the  end  of 
four  or  five  years ;  I  also  know,  however,  cases  in  which 
after  one  and  even  after  several  decades,  in  spite  of  the 
most  extraordinary  delusions,  there  could  be  no  talk  at  all 
of  real  confusion  or  at  least  not  of  a  higher  degree  of 
psychic  weakness. 

Among  my  patients  the  male  sex  preponderated  with 
60  to  70  per  cent. ;  almost  the  half  of  the  patients  were  in 
age  between  thirty  and  forty  years,  a  quarter  in  each  of  the 
decades  below  and  above  that.  In  one  case  there  w^as  at 
the  age  of  twenty-one  years  a  state  of  depression  which 
gradually  disappeared  again,  and  which  was  followed  between 
forty  and  fifty  by  the  development  of  the  delusional  attack. 
Some  of  my  patients  were  described  as  gifted,  vivacious,  but 
fantastic,  others  as  frivolous,  stubborn,  self-willed ;  several  of 
them  had  a  criminal  career  behind  them  and  fell  ill  in  prison. 

Delimitation. — In  this  form  also  it  must  remain  doubtful 
whether  it  corresponds  to  an  independent  morbid  process. 
It  cannot  be  denied  that  there  exist  many  similarities  with 
the  paranoid  forms  of  dementia  pr(Zcox,  especially  with  the 
cases  which  issue  in  drivelling  dementia ;  also  the  falling  ill 
in  prison  which  was  repeatedly  observed,  could  be  advanced 
for  this  view.  Nevertheless,  the  clinical  picture  is  so  peculiar 
that  a  separate  description  of  it  might  in  the  meantime  be 
justified,  even  though  it  should  turn  out  later  that  gradual 
transitions  to  the  forms  named  exist.  In  any  case  it  is 
noteworthy  that  here,  in  comparison  with  the  so  unusually 
severe  disorders  of  intellect,  the  injury  to  volition  by  the 
morbid  process  is  wholly  in  the  background,  if  we  do  not 
regard  a  certain  mannerism  and  the  disorders  of  speech.  In 
connection  with  this  it  must  be  emphasized  that  the  mental 
activity  of  the  patients  as  a  rule  remains  strikingly  well 
preserved.  They  may  appear  in  their  conversation  extra- 
ordinarily confused,  but  at  the  same  time  be  vivacious  and 
accessible,  and  because  of  the  absence  of  volitional  disorders 


328  DEMENTIA    PRyECOX 

act  quite  reasonably.  In  this  connection  they  recall  to  mind 
the  cases  of  confusion  of  speech  formerly  described,  from 
which,  however,  they  are  to  be  distinguished  by  the  delusions 
which  are  here  so  extremely  luxuriant.  It  might  be  con- 
ceivable that  a  nearer  relation  existed  between  these  two 
forms  or  at  least  between  parts  of  them,  as  at  present  we 
are  not  yet  able  to  judge  whether  the  peculiar  delusions 
observed  in  this  form  may  or  may  not  be  regarded  as  an 
essential  morbid  symptom.  Naturally  the  possibility  must 
also  be  remembered  that  the  cases  brought  together  here 
under  this  point  of  view  are  perhaps  among  themselves  by 
no  means  of  the  same  kind. 

The  Treatment  of  the  morbid  forms  discussed  in  this 
section  has  essentially  to  keep  in  view  only  the  timely  care 
of  the  patients  who  are  almost  always  in  need  of  institutional 
life,  and  further  the  preservation,  as  far  as  possible,  of  their 
psychic  personality  by  suitable  occupation. 


INDEX. 


Adolescent  insanity,  224 

Age,  209,  224 

Akataphasia,  70 

Alcohol,  92,  335,  241,  259,  301 

Ambitendency,  50 

Ambivalence,  50,  248 

Amentia,  275 

Aphasia,  83 

Apperceptive  dementia,  76 

Association,  19 

Association  experiments,  19,  263 

Ataxia  of  the  feelings,  35 

Attention,  5 

Autism,  49,  52,  248 

Auto-echolalia,  43 

Auto-echopraxis,  43 

Auto-intoxication,  244 

Automatic  obedience,  37,  107,  142 

Baths,  279 
Blood,  85 
Blood-pressure,  84 
Bodily  symptoms,  77,  207 

Calculation  tests,  24 

Castration,  278 

Catalepsy,  141 

Catatonia,  42,    79,    80,   86,    116,    131, 

145,  254,  257,  261,  266,  267 
Causes,  224 
—  External,  240 
Cerebro-spinal  fluid,  87 
Classification,  89 
Clinical  forms,  89 
Complexes,  35.  5i.  9i.  246 
Conduct,  96,   115,   119,  126,  136,  173, 

191,  202 
Consciousness,  17 
Constraint  of  movement,  40,  148 
thought,  22 

Degeneration,  235 
Delimitation,  252 


"D^lire  chronique,"  253,  284 
Delusions,  26,  94,   112,  118,  124,  133, 

154,  268,  284,  302,  310,  315 
Dementia,  Agitated,  116,  122 

—  Apperceptive,  76 

—  Circular,  117 

—  Confusional  speech,  177,  256,  328 

—  Delusional  depressive,  109 

—  Drivelling,  197,  206 

—  Dull,  199,  206 

—  Manneristic,  201,  206 

—  Negativistic,  203 

—  Paranoid  gravis,  154,  252 
mitis,  165,  252,  256 

—  Periodic,  129,  256 

—  Silly,  94,  200 

—  Simple  depressive,  103,  208 

—  Simplex,  90 
Derailments  in  speech,  65,  70 

train  of  thought,  72 

Diagnosis,  257 
Disintegration,  76 
Dissimulation,  273 
Drawing,  59 

Dreams,  67,  69,  247,  250 
Dyssesthesise,  167,  272,  317 

Echolalia,  39,  56,  142 
Echopraxis,  39,  142 
Electricity,  reaction  to,  79 
Emotion,  32,  74,  96,  270 
Endogenous  dementias,  i 
Engrafted  hebephrenia,  225,  260 
Epilepsy,  274 
Ergodialeipsis,  47 
Ergographic  experiments,  79 
Evasion,  21 

Flexibility,  waxy,  38,  115 

Flow  of  talk,  56 

"  Folic  morale,"  259 

Frequency,  224  ; 

Freud,  91,  246,  249 


329 


330 


INDEX 


Genkrai.  conditions  of  life,  231 
General  psychic  clinical  picture,  74 
Germ,  injury  to  the,  234 
Gibberish,  68 

Hallucinations,  7,  103,  109,  117, 
122,  13s,  1 55,  166,  193,  271,  286, 
304,  316 

Hallucinatory  verbigeration,  1 1 

Hallucinatory  weakmindedness,  192 

Hebephrenia,  89,  94,  224 

Hebephrenia,  engrafted,  225,  260 

Headaches,  77 

Hearing  of  voices,  7 

Hereditary  predisposition,  209,  332, 
258 

Hysteria,  270,  309 

Ideas,  hypochondriacal,  103*  134, 

—  of  exaltation,  29,  95,  114,  125,  135, 

158,  171,  287,  302,  310 
influence,  16,  28,  124,  X35,  287, 

317 
persecution,  27,  105,  112,  124, 

166,  284,  305,  310,  316 

reference,  31 

sin,  27,  105,  112,  124,  133 

—  sexual,  16,  30,  157,  169,  288,  318 
Idiocy,  260 

Idiosyncrasy,  personal,  235 

Imbecility,  260 

Immunization,  278 

Imprisonment,  118,  124,  133,  154,  177, 

241,  272,  327 
Impulsive  actions,  40 
Incoherence  of  thought,  20,  56 
Infections,  240 
Influence  on  thought,  12,  170 

volition,  37,  170 

Inner  negativism,  49,  51 
Inquisitiveness,  7 
"  Intellectual  negativism,"  21,  49 
Internal  speech,  67 
Intrapsychic  co-ordination,  75 

Judgment,  25 
Jung,  246,  249 

Leucocytosis,  281 
Life  traumata,  35,  51 


Mania,  308,  315 

Manic-depressive    insanity,    131,    256, 

260,  309 
Mannerisms,  45,  107,  163,  284 
Memory,  17 
Menses,  85,  129 
Mental  efliciency,  23 

—  over-eierlion,  240 
Metabolism,  86,  243 

Mood,  106,  114,  119,  125,  136,  152, 
161,  172,  178,  190,  195,  196,  198, 
199,  201,  202,  205,  267,  293,  306, 

314,  325 
Morbid  anatomy,  213 
relation  to  the  clinical  picture, 

219 
Mortality,  211 
Mutism,  65 

Negativism,  21,  47,  108,  115,  141, 
163,  265 

—  in  speech,  64 

Neologisms,  67,  140,  179,  284,  325 
Nomenclature,  3 
Nourishment,  87,  102,  144 

Obedience,    automatic,    37,     107, 

142 
Objections,  3 
Occupation,  281 
CEdipus  complex,  91 
Orientation,  17,  ill 

Packs,  wet,  279 

Parabulia,  47 

Paralogia,  21 

Paralysis,  275 

Paramimia,  75 

Paranoia,  276,  284,  300 

Paranoid  forms,  delimitation  of,  252 

Paranoid  weakmindedness,  195 

Paraphasia,  67 

Paraphrenia,  2,  253,  277,  282 

—  confabulans,  309 

—  expansiva,  302 

—  phantastica,  315 

—  systematica,  284,  308 
Parathyroidin,  278 
Pturathyroid  glands,  278 
Parergasia,  47 

Perception,  5,  105,  in,  123,  291 


INDEX 


331 


Personal  idiosyncrasy,  235 
Personality,  53,  76 
Poems,  6g,  10 1 
Practical  efficiency,  54 
Predisposition,  209,  232,  258 
Prc^nostic  indications,  205 
Prophylaxis,  279 
Pseudo-memories,    18,   159,    292,  306, 

309.  322 
Psychic  symptoms,  5 
Psychogenic  psychoses,  272 
Psychomotor  disorders,  79 
Psychopathic  states,  209,  232,  258 
Psycho-reaction,  255 
Pupils,  77,  208,  272 

Recovery,  185,  256 
—  with  defect,  186,  205 
Reflexes,  tendon,  79 
Remissions,  181 

Reproduction,  242 
Respiration,  84 
Retention,  18 

Saliva,  84 
Schizophrenia,  I,  76 
Seizures,  81,  266,  272 
Self-expression,  55 
Sex,  210,  230 
Sexual  life,  131,  242 
Simple  weakmindedness,  189 
Sleep,  87,  102 
Spasmodic  phenomena,  83 


Speaking  past  a  subject,  72 
Speech,  56,  140,  164,  179,  203 
Speech,  derailments  of,  65,  179 
Stereotypy  in  speech,  62 

train  of  thought,  2 1 

writing,  63 

movement,  43,  107,  138,  206 

Stupor,  negativistic,  50,  108,  141 
Susceptibility  to  influence,  37 
Syntax,  71 
Syphilis,  235,  241,  301 

—  cerebral,  275 

Temperature,  84 
Tendon  reflexes,  79 
Terminal  states,  185 
Thoughts  heard,  12 
Thyroid  gland,  87,  243,  278 
Traumata  of  life,  35,  51 
Treatment,  278,  302,  328 

Vasomotor  disorders,  84 
Verbigeration,  63,  140 

—  hallucinatory,  11 
Voices,  hearing  of,  7 

Volition,    37,  74,   106,   115,   127,    138, 
198,  200 

Waxy  flexibility,  38,  115 
Weakmindedness,    hallucinatory,    192, 
206 

—  paranoid,  195,  206 

—  simple,  189,  205 
Writing,  57,  99,  174 


J.    &  J.    gray   &   CO.;    printers,    EDINBURGH 


L' 


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